< Previous38 American Nurse Journal Volume 15, Number 2 T he January 31 topic of OJIN: The Online Journal of Issues in Nursing celebrates nurses and offers examples of practice changes by individual nurses and nursing organizations. Check out the six new articles in “The Year of the Nurse in 2020: Nurse led initiatives in policy, practice, and education.” “Nurses leading the way to better support family caregivers,” by Susan C. Reinhard, PhD, RN, FAAN, and Andrea Brassard, PhD, FNP-BC, FAAN, summa- rizes current evidence from the AARP Survey Find- ings and Update to inform nurses and other provid- ers about how to educate family caregivers through resources and discuss proactive outreach based on the CARE Act. Authors Ellen Martin, PhD, RN, CPHQ, CPPS, and Cindy Zolnierek, PhD, RN, CAE, offer exemplars il- lustrating state-level policies that regulate the prac- tice environment and discuss protections in “Be- yond the nurse practice act: Making a difference through advocacy.” “A nursing approach to the largest measles outbreak in recent U.S. history: Lessons learned battling home- grown vaccine hesitancy,” by Blima Marcus, DNP, RN, ANP-BC, OCN, describes this nurse-led outreach, provides useful tips to address vaccine hesitancy, and offers evidence-based answers to vaccine myths. Sofia A. Aragon, JD, BSN, RN, and her colleagues share the successes of Action Now!, a movement spearheaded by the Washington Center for Nursing, the Washington Board of Nursing, and the Council on Nursing Education in Washington State in the article, “Nurses at the table: Action Now! for nursing educa- tion.” In “Learning about rurality: From classroom to com- munity,” Ruth Mielke, PhD, CNM, WHNP-BC, FACNM, and colleagues share the experience of preparing women’s health advanced practice RNs to serve a population in rural California. Authors Michael Villeneuve, MSc, RN, FAAN, and Claire Betker, PhD, MN, RN, CCHN(c), offer examples of the impact of Canadian nurses and nursing associ- ations to build, overhaul, and improve health systems and influence health policy in their article, “Nurses, nursing associations, and health systems evolutions in Canada.” Read these stories and more at ojin.nursingworld.org. OJIN rings in the Year of the Nurse ANA NEWS Statement of ANA position ANA believes that nurses must provide compas- sionate, comprehensive, and person-centered care to all people, inclusive of at-risk populations such as people with IDD who experience health disparities across practice settings. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or popu- lation, according to the ANA Code of Ethics for Nurses with Interpretive Statements . By virtue of their disability, people with IDD often require support across the lifespan, which encompasses support for the individual, family, caregiver, and community. Nursing care for people with IDD should focus on individual needs and strengths, rather than a diagnosis or label. Nurses are well positioned to advocate for the rights of people with IDD, as well as protect them from potential- ly harmful factors, such as victimization, abuse, neglect, and discrimination. Read the full statement on nursingworld.org at (bit.ly/36QAwfE). Making a difference P eople with intellectual and developmental disabilities (IDD) experience myriad dispar- ities related to healthcare and access to it. In 2019, the American Nurses Association (ANA) Board of Directors approved a position state- ment, Nurse’s Role in Providing Ethically and De- velopmentally Appropriate Care to People with Intellectual and Developmental Disabilities . This position statement is intended to support people with IDD by respecting and understanding differ- ences and enabling them to realize their full po- tential in health situations while building on exist- ing strengths and skills as active, engaged citizens, so that others can benefit from their tal- ents and abilities. February 2020 American Nurse Journal 39 To: Ethics inbox From: Concerned RN Subject: Bedside arraignments I am a medical-surgical nurse and admitted a pa- tient to my unit who was arrested and injured during the commission of an alleged crime. The hospital allowed a television news crew to come in- to my patient’s room and record his court arraign- ment, which will be aired on a local station. I feel this was a violation of patient privacy. How is this fair and what should I have done? From: ANA Center for Ethics and Human Rights Thank you for sending this challenging dilemma. First, the nurse’s ethical obligation is to the patient. Be sure your patient is medically stable and that you and your colleagues are safe. Next, determine if your hospital has a policy or resources to help resolve the issue so you can focus on patient care. Ideally, a person charged with a crime has a formal reading of charges filed in a courtroom. These ar- raignments can involve videotaping the process to prevent having to transport defendants to the court- room. However, an ethical dilemma presents when those charged become patients in a hospital, with the possibility of the arraignment being televised publicly. To understand the obligations of nurses in this situation, it’s important to understand the need to maintain the duty of care by protecting the rights of vulnerable populations, including the right to pri- vacy and confidentiality. The Code of Ethics for Nurses with Interpretive Statements (nursingworld.org/coe-view-only) spec- ifies that nurses must preserve the rights of vulner- able groups, including those who may be socially stigmatized. Nurses must safeguard the right to privacy for all patients. Provision 3.1 states, “The need for healthcare does not justify unwanted, un- necessary, or unwarranted intrusion into a person’s life. Privacy is the right to control access to, and disclosure or nondisclosure of, information pertain- ing to oneself and to control the circumstances, timing, and extent to which information may be disclosed.” Televised arraignments at the bedside may involve publicizing private patient information, including his or her location, that the patient hasn’t authorized. Furthermore, revealing this information could be un- safe for nurses and others at the hospital. For exam- ple, furtherance of the original alleged crime or acts of retaliation may place other pa- tients and staff at risk. Interpretive Statement 3.1 asserts that nurses must advocate for environments that “provide sufficient physical privacy, including privacy for dis- cussions of a personal nature.” As advocates for the patient, nurses must be vigilant in pursuing policy guidance from hospital leaders to address the privacy concerns and legality of the arraignment. Patient advocacy requires assess- ment of the patient’s condition. This should include how the pa- tient clinically responds to the ar- raignment and whether the condi- tions of the arraignment lead to health complications. The nurse also must determine whether the hospital arraignment is ethically appropriate for the patient. Nurses should consider factors such as safety, pa- tient autonomy, privacy, respect, and trust. Trust is central to the nurse-patient relationship (In- terpretive Statement 3.1), so nurses should help en- sure that personal health information is protected. Nurses are encouraged to demonstrate moral cour- age and advocate for patients in these difficult and often time-pressured situations. If nurses are work- ing in organizations that lack policies or standards regarding recording or videotaping patients, they are encouraged to bring these concerns to the orga- nization’s leadership team. — Response by Renata Iskander, intern, ANA Center for Ethics and Human Rights, and Liz Stokes, JD, MA, RN, director, ANA Center for Ethics and Human Rights Ethics of bedside arraignments Reference Legal Information Institute. Rule 10. Arraignment. law.cornell. edu/rules/frcrmp/rule_10 Do you have a question for the Ethics Inbox? Submit at ethics@ana.org. FROM THE ETHICS INBOX40 American Nurse Journal Volume 15, Number 2 W hen the ANA Enterprise launched Healthy Nurse, Healthy Nation TM (HNHN) with the goal of transforming the health of the na- tion by improving the health of the nation’s registered nurses, it was clear that support would be need- ed from others who care about nurses. The newest champion of nurses’ health is a global leader in healthcare support services— Compass One Healthcare. A com- bination of Crothall Healthcare and Morrison Healthcare, Compass One Healthcare has expertise in food and nutrition and provides a variety of other services including facilities management, laundry and linen, and patient transport. All of their business lines touch nursing in some way. Now they will join the HNHN national movement as a partner to support content and challenges related to nutrition. Nurses tend to have a suboptimum diet. The Office of Disease Prevention and Health Promotion and Di- etary Guidelines for Americans recommend that all individuals eat between three to five servings of whole grains and five to nine servings of fruits and vegetables daily. But in a 2019 HNHN survey, 72% of nurses said they consume three or fewer servings of fruits and vegetables daily. In the same survey, 30% of nurses said they don’t feel they have access to healthy food choices at work. Research shows that when clinicians are healthy, they provide better counsel to patients about healthy be- haviors. Research also has linked nutrition quality to decision making. “We need to innovate to help nurses be as healthy as they want to and can be. It requires us to engage with the most creative, committed healthcare partners,” said American Nurses Foundation Executive Director Kate Judge. “We believe our work with Com- pass One will inspire new solu- tions that can help nurses across the country and the globe. That, in turn, will help improve the health of patients.” “In our healthcare space, nursing is the cornerstone,” said Senior Vice President of Stra- tegic Partnerships Bart Kaericher. “That’s why this partnership with Healthy Nurse, Healthy Nation is so exciting for us. We can make a huge difference for our nurse partners by offering healthy and delicious meals and by taking some of the stress off by providing a safe environment of care.” HNHN engages more than 500 partner organizations and over 130,000 participants to act in five key do- mains—physical activity, rest, nutrition, quality of life, and safety. Both individuals and organizational part- ners can learn about HNHN by visiting hnhn.org. To make a financial contribution and support nurses’ health visit givetonursing.org. A merican Nurses Association (ANA) President Ernest Grant, PhD, RN, FAAN, officially kicked off the Year of the Nurse with a live interview January 14 on NPR’s 1A program. Grant and ANA Past President Pamela Cipriano, PhD, RN, NEA- BC, FAAN, shared insights on the state of nursing today, the challenges of the profes- sion and the value of nurses. Listen to the program and share the link (the1a.org/ shows/2020-01-14/calling-the-shots-in-the- year-of-the-nurse-and-midwife) with colleagues, friends, and via your social media channels. The ANA Enterprise is elevating and celebrating the essential, robust contributions of nurses as the world recognizes 2020 as the “Year of the Nurse.” By high- lighting the vital role of nurses, we aim to spur ex- panded investment in education, practice, and research, as well as increase the number of nurses who serve in leadership positions. Despite the high regard of the public, nurs- es are wholly underrepresented in media coverage of health care issues. Additionally, many myths and misperceptions about nursing persist. To help address this, we are asking nurses to share their stories, photos, and videos with ANA to help us communi- cate a contemporary and accurate view of nurses and the critical work we do. Be sure to visit ANA’s Year of the Nurse webpage (pages.nursingworld.org/yearofthenurse) for the of- ficial Year of the Nurse logo and updates on future activities. We can’t do it alone Kicking off the Year of the Nurse on NPR FOUNDATION NEWS ANA ENTERPRISE NEWSMyAmericanNurse.com February 2020 American Nurse Journal 41 PRACTICE MATTERS Key components for optimal staffing New principles help make this complex goal attainable. By Kendra McMillan, MPH, RN N URSE STAFFING is essential to the delivery of safe, quality healthcare in every practice setting. Nurses have a unique knowledge and under- standing of how to respond to changing patient and unit needs, making them critical stakehold- ers in staffing decisions and how those deci- sions play out. Staffing is more than just num- bers; it’s an equitable distribution of nursing resources across units and shifts. So, what’s necessary to make optimal staffing a reality? In 2019, the American Nurses Association (ANA) released an update to its Principles for Nurse Staffing ( nursingworld.org/PrinciplesFor NurseStaffing ). The principles address the key components needed to achieve optimal staffing and patient outcomes, as described here. The patient. Staffing decisions should be based on individual patient needs, stability, di- agnosis severity, and required care. What’s the level of direct care needed per patient and what are the care and discharge planning needs? Also consider age- and language-spe- cific resources, time spent on transfers off the unit for procedures, patient and family educa- tional needs, and the availability of family and social support. Staffing guidelines should be based on patient safety indicators and accom- panied by enough resource allocation for care coordination and patient education. Nurse and healthcare team. The nurse’s individual characteristics—including experi- ence, knowledge, skill set, educational prepa- ration, and competence with technology and clinical interventions—directly affect care out- comes. After considering the patient’s needs, what’s the skill level of the nurse and health- care team, and how do you match the two? Does the person in charge of staffing under- stand the skill level of each healthcare team member to ensure appropriate matching? Are ancillary staff available to carry out non-nurs- ing tasks? Staffing plans require flexibility to adapt to changes in patient status and to ac- commodate for admissions, transfers, and dis- charges. Staffing also must account for the al- location of time and resources needed for mentoring and skill development activities. Organization and workplace culture. Optimal staffing balances safe, quality care with nursing resources and costs. When achieved, nurses are practicing to the full extent of their education and licensure and have the neces- sary resources to provide care. A healthy work environment with a value-based culture that supports respect, trust, collaboration, and eth- ical decision-making within the healthcare team is essential to patient care and staffing alignment, and it’s vital for nurse satisfaction. Practice environment. A culture of safety plays an integral role in achieving appropriate staffing. Unit-by-unit changes within a shift re- quire continuous monitoring and real-time ad- justments to provide optimal care. A supportive practice environment with clear policies facili- tates nurse well-being and allows adequate time for meal and bathroom breaks, overtime regula- tion, and limits on shift length to ensure that staff health and safety needs are met. Nurses have a professional obligation to report unsafe conditions and inappropriate staffing levels and the right to do so without the fear of reprisal. Evaluation. The evaluation plan must be valid and reliable and accurately capture the outcomes, costs, and time needed to provide nursing care. Ongoing assessment of an orga- nization’s overall health with respect to turnover, retention, frequency of overtime, and the need for supplemental staffing also are es- sential elements to watch. Appropriate nurse staffing is an asset to our ever-evolving healthcare system. Viable solu- tions for optimal staffing may be complex, but they are attainable. AN Kendra McMillan is senior policy advisor for the American Nurses Association, Nursing Practice and Work Environment department. A culture of safety plays an integral role in achieving appropriate staffing.42 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com Ultrasound-guided I.V. catheter insertion Standardized protocols and education can improve patient safety, reduce costs, and enhance nursing practice. By Carrie A. Cromwell, MS, APRN, CRNA, and Alice L. March, PhD, RN, FNP, CNE E STABLISHING peripheral I.V. access is an es- sential, high-priority nursing procedure. How- ever, access sometimes can be difficult to ob- tain even for experienced clinicians. Recently, the evidence-based ultrasound-guided short peripheral catheter (USGSPC) insertion method has been established as effective when caring for patients with difficult venous access. The success rate is high, and the added advantages of improved accuracy and more timely inser- tion increase patient safety and satisfaction. However, recent research demonstrates that USGSPC insertion hasn’t been widely adopted. This may be due to a lack of awareness or an absence of organizational protocols for training and use. To increase adoption of USGSPC, nurses first need to understand its benefits and use. They will then be well positioned to integrate the method into nursing education and imple- ment it in clinical practice. Why USGSPC? According to Hunter and colleagues, approxi- mately 90% of hospitalized patients require some form of peripheral venous access, yet this procedure can be difficult to complete, with at least one study (Whalen and col- leagues) suggesting that up to 50% of children and 35% of adults have difficult venous ac- cess. (See Difficult access. ) When performed properly, short peripheral catheter (SPC) insertion is a safe procedure with minimal serious risks. When insertion can’t be achieved using traditional direct visu- alization, palpation, or landmark-based tech- niques, ultrasound provides a high rate of suc- cess with substantial benefits for both patients and nurses. USGSPC insertion benefits The 2016 Infusion Therapy Standards of Prac- tice state that no more than two attempts at SPC insertion should be made per clinician, with no more than four total attempts. Quickly and efficiently obtaining I.V. access using ul- trasound guidance in patients with difficult venous access reduces the number of at- tempts, increases success rates, and decreas - es insertion pain. It also reduces care delays, provides cost and time savings, improves pa- tient satisfaction, reduces nurse and provider frustration, and attenuates the complications of multiple attempts or more invasive proce- dures (Miles and colleagues and Shokoohi and colleagues report that USGSPC insertion performed by trained nurses can decrease STRICTLY CLINICALMyAmericanNurse.com February 2020 American Nurse Journal 43 the need for central venous catheter [CVC] placement by as much as 74% to 80%). Nursing implications In most healthcare organizations, a provider, specialty trained vascular access nurse, or oth- er ultrasound-proficient healthcare profession- al uses the USGSPC procedure to obtain can- nulation only after a nurse is unsuccessful with traditional techniques. However, evi- dence shows that with structured training, nurses can effectively use the USGSPC method (Feinsmith and colleagues report con- sistent success rates as high as 96%). In a study by Edwards and Jones, nine out of 10 nurses agreed that dedicated training ade- quately prepared them to use ultrasound guidance for insertion, and seven out of 10 found actual placement to be easy. According to Bahl and colleagues, nurses using the US- GSPC technique after completing training were more likely to achieve cannulation com- pared to nurses using standard visualization and palpation, and the time required to com- plete the procedure was shortened. Many large academic healthcare organiza- tions have dedicated vascular access teams composed of experts in difficult venous ac- cess. These multidisciplinary teams, which fre- quently include nurses trained in USGSPC in- sertion, identify patients with difficult venous access and intervene early to establish time- ly insertion. Across the United States, state boards of nursing do not require board certi- fication for vascular access nurse specialists; however, many state laws do require that healthcare organizations have written policies and procedures to ensure that nurses dem - onstrate and maintain competency. With in- creased access to educational resources and technology (guided by organizational policies and procedures), USGSPC insertion training that includes staff nurses who routinely obtain venous access could reasonably be achieved. USGSPC implementation The 2016 Infusion Therapy Standards of Prac- tice state that only nurses who possess the ap- propriate skills and validated competencies should insert SPCs, but the literature reveals that even traditional SPC insertion education is inconsistent. To ensure nurses can efficiently, safely, and comfortably perform USGSPC in- sertion, enhanced organizational SPC curricu- lum should include standardized, evidence- based USGSPC training and use protocols. (See Education basics.) The protocols should encompass training expectations and curricu- lum, skills assessment and maintenance, and portable ultrasound equipment availability. Guidelines and protocols are readily available to help facilitate implementing USGSPC inser- tion into nursing practice. Video tutorials, such as one published by The New England Journal of Medicine, demonstrate the technique. And a formal online training course for teaching and learning the USGSPC insertion technique is available at IvyLeagueNurse.com. With so many resources and evidence-based materials avail- able, developing a structured hands-on training curriculum and obtaining proficiency in US- Patients with difficult venous access include those with: • obesity • a history of I.V. drug use • multiple chronic illnesses. Some pathophysiologic changes also may decrease the ability to use traditional visualization when inserting a short peripheral catheter. These conditions include: • edema • hypovolemia • vascular pathology. Two out of every five patients require multiple attempts to achieve I.V. access, sometimes taking 30 minutes or more to complete. The result can be: • patient pain and discomfort • lack of blood specimens • delayed diagnosis and treatment • decreased nurse productivity • increased supply costs • increased likelihood of using a more expensive high-risk procedure, such as central venous catheter (CVC) insertion. CVC risks Inserting and maintaining a CVC can be dangerous, exposing patients to serious complications including: • catheter-associated bloodstream infections • large vessel injuries • hematomas • cardiac arrhythmias • venous air embolisms • pneumothorax. Difficult access44 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com GSPC insertion is attainable for nurses in all geo - graphic areas and practice settings. Spreading the word Sufficient research exists to support USGSPC for patients with difficult venous access; how- ever, many nurses still don’t use the tech- nique. Nurses can take the lead in encourag- ing USGSPC implementation in practice so patients can reap the benefits. AN Carrie A. Cromwell is a certified registered nurse anesthetist at the Central Texas Veterans Health Care System in Temple and a doctor of nursing practice student and Jonas Veterans Healthcare Scholar at the University of Alabama Capstone College of Nursing in Tus ca - loosa. Alice L. March is a professor at the University of Alabama Capstone College of Nursing. References American Institute of Ultrasound in Medicine. AIUM practice parameter for the use of ultrasound to guide vascular access procedures. J Ultrasound Med . 2019;38(3):E4-E18. Arnold K. Ultrasound guided peripheral IV insertion. Ivy LeagueNurse.com. November 11, 2014. ivyleaguenurse.com/ courses/Ultrasound_Guided_PIVs.pdf. Bahl A, Pandurangadu AV, Tucker J, Bagan M. A random ized controlled trial assessing the use of ultrasound for nurse-per- formed IV placement in difficult access ED patients. Am J Emerg Med. 2016;34(10):1950-4. Björkander M, Bentzer P, Schött U, Broman ME, Kander T. Mechanical complications of central venous catheter inser- tions: A retrospective multicenter study of incidence and risks. Acta Anaesthesiol Scand. 2019;63(1):61-8. Chopra V, Kuhn L, Vaughn V, et al. Does certification in vas- cular access matter? An analysis of the PICC1 survey. Am J Nurs. 2017;117(12):24-34. Dietrich CF, Horn R, Morf S, et al. US-guided peripheral vascular interventions, comments on the EFSUMB guide- lines. Med Ultrason. 2016;18(2):231-9. Edwards C, Jones J. Development and implementation of an ultrasound-guided peripheral intravenous catheter program for emergency nurses. J Emerg Nurs. 2018;44(1):33-6. Feinsmith S, Huebinger R, Pitts M, Baran E, Haas S. Out- comes of a simplified ultrasound-guided intravenous train- ing course for emergency nurses. J Emerg Nurs. 2018;44(2): 169-75. Gorski LA. The 2016 Infusion Therapy Standards of Practice. Home Healthc Now. 2017;35(1):10-8. Gosselin É, Lapré J, Lavoie S, Rhein S. Cost-effectiveness of introducing a nursing-based programme of ultrasound-guid- ed peripheral venous access in a regional teaching hospital. J Nurs Manag. 2017;25(5):339-45. Haddadin Y, Regunath H. Central line associated blood stream infections (CLABSI). StatPearls. December 9, 2019. ncbi.nlm.nih.gov/books/NBK430891 Hunter MR, Vandenhouten C, Raynak A, Owens AK, Thomp- son J. Addressing the silence: A need for peripheral intra- venous education in North America. J Assoc Vasc Access. 2018;23(3):157-65. İsmailoğlu EG, Zaybak A, Akarca FK, Kiyan S. The effect of the use of ultrasound in the success of peripheral venous catheterisation. Int Emerg Nurs. 2015;23(2):89-93. Joing S, Strote S, Caroon L, et al. Ultrasound-guided peripher- al IV placement. NEJM. August 4, 2012. youtube.com/watch ?v=-fduIjQ8EH4&t=6s McCarthy ML, Shokoohi H, Boniface KS, et al. Ultrasonog- raphy versus landmark for peripheral intravenous cannula- tion: A randomized controlled trial. Ann Emerg Med. 2016; 68(1):10-8. Miles G, Salcedo A, Spear D. Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emerg Nurs. 2012;38(4):353-6. National Healthcare Safety Network. Central line-associat- ed bloodstream infections (CLABSI). nhsn.cdc.gov/nhsn training/courses/2018/C04 Oliveira L, Lawrence M. Ultrasound-guided peripheral intra- venous access program for emergency physicians, nurses, and corpsmen (technicians) at a military hospital. Mil Med . 2016;181(3):272-6. Pare JR, Pollock SE, Liu JH, Leo MM, Nelson KP. Central ve- nous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients. Am J Emerg Med . 2019;37(2):317-20. Shokoohi H, Boniface K, McCarthy M, et al. Ultrasound-guid- ed peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncrit- ically ill emergency department patients. Ann Emerg Med. 2013;61(2):198-203. Stolz LA, Stolz U, Howe C, Farrell IJ, Adhikari S. Ultrasound- guided peripheral venous access: A meta-analysis and sys- tematic review. J Vasc Access. 2015;16(4):321-6. Weiner SG, Sarff AR, Esener DE, et al. Single-operator ultra- sound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in pa- tients with difficult-to-establish intravenous access. J Emerg Med. 2013;44(3):653-60. Whalen M, Maliszewski B, Baptiste DL. Establishing a dedi- cated difficult vascular access team in the emergency depart- ment: A needs assessment. J Infus Nurs. 2017;40(3):149-54. With basic education and hands-on practice with the ultrasound- guided short peripheral catheter insertion method, nurses can achieve a high level of I.V. access success. Nurse education and train- ing should include: • basic ultrasound knowledge, including how to operate the machine and identify venous structures • knowledge of vascular anatomy and vessel selection • an awareness of vein depth, catheter insertion angle, and catheter length to facilitate safe and effective insertion • skills such as how to hold the probe, view the needle, and identify successful cannulation. Education basicsMyAmericanNurse.com February 2020 American Nurse Journal 45 PRACTICE MATTERS Shared decision making and patient-centered care Engage patients in healthcare decisions to ensure patient autonomy. By Christy L. Skelly, DNP, APRN, WHNP-BC; Carrie Ann Hall, PhD, APRN, FNP-C; and Carrie R. Risher, DNP, MA(Ed), CMSRN P ATIENTS have to make many healthcare deci- sions during hospital stays and throughout care. These decisions can vary dramatically in context and severity. For example, one patient may need to choose the type of facility he or she will be discharged to and another may need to make a simple medication or activity decision. Nurses understand the importance of patient autonomy and that ultimately all de- cisions are up to the patient. However, many barriers can make that process difficult. (See Decision-making barriers.) A 2017 study by Burke and colleagues of 54 patients and professional caregivers mak- ing decisions about skilled care after hospital discharge found that patients frequently felt passive in their care decision-making and felt an overall lack of autonomy. Nurses can help change this by practicing shared decision making (SDM), which engages patients in making active choices about their care. As SDM becomes standard in healthcare organi- zations, various decision-making models are being developed, and the National Quality Fo- rum is designing certification standards for pa- tient decision aids used in the United States. Implementing a decision-making model that includes patients can improve care quality. SDM: A closer look According to the National Learning Consor- tium, SDM is the process by which patients actively work with a nurse or other healthcare professional to make informed decisions about their healthcare options. As part of pa- tient-centered care, SDM is critical when a pa- tient is faced with multiple healthcare options with varied benefits and risks. SDM is associ- ated with increased patient knowledge, satis- faction, and confidence with healthcare deci- sions. In addition, researchers have found that it improves patient autonomy and disease self- management. SDM stems from the 1978 International Conference on Primary Health Care Declara- tion of Alma-Ata that recognized the impor- tance of patients actively participating in all aspects of their care, including planning, or- ganizing, and implementing care decisions. Since then, several steps have been taken in support of SDM. For example, the National Academies of Sciences, Engineering, and Med - i cine recommends adopting SDM into patient care delivery, the Agency for Healthcare Re- search and Quality (AHRQ) notes the impor- tance of providing patients and their families with evidence-based care options in accessi- ble formats that take into account individual learning and cultural needs, and the Patient Protection and Affordable Care Act supports 46 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com SDM that includes the healthcare team, pa- tients, and caregivers. In addition, Quality and Safety Education for Nurses competencies in- clude preparing nurses to foster and support SDM. SDM also is supported by the American Nurses Association Code of Ethics for Nurses with Interpretive Statements and Nursing Scope and Standards of Practice. To facilitate SDM, nurses need to under- stand the process. Truglio-Londrigan has iden- tified nine competencies—reflective practice, nurse-patient relationship, communication, as- sessment, cultural knowing, teaching and learning, ethical knowing, interprofessional practice, and negotiation—necessary for nurs- es to practice SDM. (See Build your compe- tence.) Combining these competencies with an effective decision-making model helps en- sure that care remains patient centered. The SHARE Approach model The AHRQ SHARE Approach decision-making model is designed to guide SDM by examining and analyzing healthcare option advantages, disadvantages, and potential risks. The options are identified via meaningful patient-nurse di- alogue that allows the patient to openly ex- press what’s most important to him or her. The model comprises this five-step process: Seek your patient’s participation. Help your patient explore and compare treat- ment options. A ssess your patient’s values and preferences. R each a decision with your patient. E valuate your patient’s decision. According to AHRQ, benefits of the SHARE Approach include increased patient satisfac- tion resulting from improved care quality and a good care experience. The model also helps build trust between healthcare professionals and patients. AHRQ offers a workshop cur- riculum (User’s Guide for Clinical Teams, avail- able at ahrq.gov/shareddecisionmaking ) with resources and tools for teaching nurses how to implement the SHARE Approach. Putting SDM into practice starts with lead- To ensure patient participation in shared decision making (SDM), build these competencies: • Reflective practice: Engage in reflection. Patient and nurse reflec- tion should occur while the SDM process is underway and after it’s complete to identify areas of strength and opportunities to improve. • Nurse-patient relationship: Be mindful of patients’ goals and needs; doing so will help you develop meaningful, therapeutic rela- tionships that foster SDM. • Communication: Communicate effectively with patients, families, communities, interprofessional teams, and organization leadership to ensure that patient needs are heard and shared with the health- care team. • Assessment: Assess the patient’s ability to engage in SDM so you can modify resources and techniques based on individual patient characteristics. For example, consider the patient’s developmental stage, literacy level, disease severity, and treatment options to guide SDM planning and engagement. • Cultural knowing: Respect and value individual patients’ cultural differences so you can identify healthcare choices that align with their beliefs. • Teaching and learning: Design a teaching plan that accounts for patients’ specific needs (developmental age, literacy level, cultural considerations, primary language, learning style, and any needed accommodations). • Ethical knowing: Understand and balance ethical principles while engaging in SDM. For example, a patient’s choice may conflict with your values and beliefs, but you’ll still need to ensure that the pa- tient is fully supported. • Interprofessional practice: Nurses facilitate SDM with the health- care team as well as the patient, so take into consideration each team member’s expertise and how it supports the best patient care. • Negotiation: When conflict arises, work with the patient, family members, and healthcare team to facilitate understanding of op- posing views, identify commonalities, and promote a shared deci- sion. Use strategies that foster collaborative agreements and be open to seeking an understanding of each person’s views. Build your competence Patient autonomy is crucial to patient-centered care, but several barriers can prevent patients from participating in healthcare decisions. Those barriers include: • insufficient knowledge • limited time • lack of experience • no family support • reduced mental capacity • inadequate resources. Nurses also may encounter barriers, includ- ing limited time and lack of knowledge and confidence about certain topics or resources. In addition, family members may disagree with a patient’s decision or doubt the provided in- formation. Decision-making barriers ership buy-in and a well-coordinated plan. In addition, the AHRQ user’s guide recommends creating an implementation team, adopting an approach that fits your practice, providing staff training and ongoing support, taking an incremental approach by starting small and then increasing over time, creating a physical space for SDM, building a library of evidence- based resources and decision aids, integrating SDM processes into daily care, and evaluating ongoing SDM implementation. Follow the evidence Nurses who strive to provide quality care should follow the evidence that leads to best practices. A team-based approach to SDM enables patients to examine their options and actively participate in their healthcare. The result is improved outcomes, care qual- ity, and patient satisfaction. AN To view a list of references, visit myamericannurse.com/ ?p=64346. Christy L. Skelly, Carrie Ann Hall, and Carrie R. Risher are assistant professors of nursing at Florida Southern College in Lakeland. A D I NDEX American Nurses Association/American Nurses Credentialing Center ANA’s Principles for Nurse Staffing ..................... 23 ANCC Accreditation NCPD Summit ...................... 5 ANCC Pathway to Excellence Conference® ........ 15 The Washington Post/ANA Star Nurses .............. IFC Berkshire Hathaway Specialty Insurance ................. IBC Exergen Corporation ...................................... Cover Tip Hewlett Packard Inc. (HP) ........................................ BC Mercer Consumer ...................................................... 13 Monmouth Medical Center – RWJBarnabas ................. 9 National Institute of Whole Health ............................ 47 For advertising and partnership information please contact John J. Travaline 215-489-7000 jtravaline@healthcommedia.com Go Beyond Symptomatic Care ™ Earn Credentials in an Additional Scope of Practice as a Patient Health Educator, Advocate and Coach Provide your patients with the What, Why and How of their chronic health concerns and empower them with a demystified understanding of how they can reduce or prevent disease and increase longevity. Nationally accredited by the Institute for Credentialing Excellence – which accredits 15 nurse specialty trainings – this 400 hour program provides 200 ANCC approved contact hours and leads to Health Care Provider status and an NPI number as a patient health educator, to be used in today’s medical environments or your own private practice. 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