< Previous8 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com are ordering them more frequently than oth- ers. You may discover indications for use of antipsychotic medications that are vague or not clinically justified, such as for agitation, aggressiveness, or resistance to care. Don’t as- sume behavioral and psychological symptoms in residents with dementia are psychotic and should be managed with antipsychotic med- ications. Consider behavioral expressions as communication of unmet needs, such as fear, hunger, pain, or a need to use the bathroom. Set a goal Once you truly understand what’s driving an- tipsychotic use in residents with dementia, set an overall reduction goal. Some nursing homes have a higher percentage of residents with psy- chiatric disorder diagnoses. Antipsychotic use may be appropriate when clinically indicated, but it should be carefully examined and moni- tored. Use your Facility Characteristics Report from CMS to assess how care of your residents compares to care of residents in other nursing homes in your state and the nation. According to CMS, the five states with the lowest antipsychotic use in nursing homes have average rates between 7.2% and 11.2%, well below the 14.6% national average. Guide your interprofessional team in setting a nu- meric and timebound goal to support reduc- ing antipsychotic medication use. For exam- ple, your goal might be to reduce the percent- age of long-stay residents taking an antipsy- chotic medication from 21% to at or below the state average of 13% in 6 months. Lay the groundwork for improvement Before beginning any ordered systematic dosage reductions, lay the groundwork for im- provement, which should include identifying and implementing best practices, evaluating individual residents’ needs, ensuring mental and physical stimulation, promoting restorative sleep, and assessing the environment. Best practices Begin by reviewing current evidence and guide- lines for pharmacologic and nonpharmacologic approaches to dementia care. Provide training, education, and coaching for direct care and sup- port staff so they can better understand and communicate with residents with dementia. Staff must know how to listen, speak, act, and react in ways that create meaningful interactions. Individual resident needs Carefully observe and look for patterns in how each resident responds to different interactions or sensory stimuli. Consistent assignments can help staff get to know each resident and iden- tify patterns. Learn what nonpharmacologic in- terventions are most effective for individual residents if they become anxious, fearful, ag- gressive, or resistant to care. Always assess for pain and comfort first and follow up with ap- propriate interventions (pain management, repositioning), especially if the resident can’t make his or her needs known. (See Nonphar- macologic care approaches.) To help avoid in- appropriate antipsychotic use, document and communicate specific triggers or behavioral re- sponses to all care team members. Mental and physical stimulation Consider how your residents’ days are struc- tured. Activities of daily living training can help improve executive function, physical endurance, and depressed mood of nursing home residents with dementia, even if it is moderately severe. (You can find several dementia rating scales at dementiacare central.com/aboutdementia/facts/stages/#scales ). Provide meaningful engagement with staff and other residents throughout the day, and Share these useful resources. Antipsychotics in nursing home basics • American Health Care Association/National Center for Assisted Liv- ing Quality Initiative—Fast facts: What You Need to Know About An- tipsychotic Drugs for Persons Living with Dementia. ahcancal.org/quality_improvement/qualityinitiative/Documents/ Antipsychotics%20Consumer%20Fact%20Sheet%20-%20English.pdf • National Nursing Home Quality Improvement Campaign—Use Med- ications Appropriately: Probing Questions. qioprogram.org/sites/default/files/Probing_Questions_Medications.pdf Dementia care • Alzheimer’s Association—Behaviors: How to Respond When Dementia Causes Unpredictable Behaviors. alz.org/national/documents/brochure_behaviors.pdf • Centers for Medicare & Medicaid Services. Quality, Safety & Education Portal—CMS hand in hand training—A training series for nursing homes. qsep.cms.gov/pubs/HandinHand.aspx Guidelines for supporting residents living with dementia • Alzheimer’s Association—Dementia care practice recommendations. alz.org/professionals/professional-providers/dementia_care_prac- tice_recommendations • American Psychiatric Association—Practice guideline on the use of an- tipsychotics to treat agitation or psychosis in patients with dementia. psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807 Share informationMyAmericanNurse.com March 2020 American Nurse Journal 9 include activity and exercise to maintain mobility, reduce boredom and fatigue, and decrease over- or understimulation. Sleep promotion Lack of restorative sleep, which prevents a person from completing all five stages of sleep, decreases the body’s ability to heal and repair itself. The result can be irritability that’s incorrectly attributed to behaviors associated with dementia and inappropriately treated with antipsychotics. Provide a quiet environ- ment at night that’s conducive to sleep. Staff may need to enter residents’ rooms to provide care (including assistance with using the bathroom and help with repositioning) dur- ing the night, but examine these routines to minimize sleep disruption. In a study by Corbett of staff who received training and materials on person-centered care of residents with dementia experiencing sleep problems, changes to night- time care plans resulted in improved behavioral and psychological symptoms of dementia. Environment assessment Environmental factors such as loud or com- peting noises, clutter, or lack of personal space can trigger or exacerbate behavioral or psychological symptoms. Although structural modifications might not be possible, changes to problematic areas may be helpful. Conduct a simple assessment by personally experienc- ing the space in the same way a resident does. For example, sit in a common area, eat in the dining area, or participate in an activity. Note all of the potential sensory triggers and ex- plore how the environment can be adapted or modified to reduce them. Reduce antipsychotic medication use Reducing the use of antipsychotic medications requires working with providers, implement- ing a systematic approach, and involving res- idents and families. Work with providers Share your nursing home’s goal to reduce an- tipsychotic medication use and work directly with providers. Start communication before a resident is admitted to your nursing home. For example, if the resident is coming from a hos- pital, speak to the discharge planner to under- stand when and why an antipsychotic medica- tion was started to determine whether it can be reduced or discontinued upon admission. As providers assess residents, share informa- tion about nonpharmacologic interventions available as alternatives to antipsychotics. To avoid antipsychotics being prescribed by on- call clinicians or others not familiar with your nursing home, designate a gatekeeper (such as the director of nursing) to review all re- quests for new antipsychotic medications be- fore sending the order to the pharmacy. Implement systematic dose reductions Work with providers and the care team to identify and prioritize residents for gradual an- tipsychotic dose reduction. For example, resi- dents may be good candidates for successful reduction if they use antipsychotics as needed, recently started the antipsychotic for transient agitation or sleep, were prescribed the medica- tion for delirium while in the hospital, or have late-stage dementia and sleep most of the time. Frequently, antipsychotics are started with- out a plan for gradual dose reduction. A taper- ing plan should be started early, unless clini- cally contraindicated, so the resident, family, and staff expect it. CMS requirements state that trials of gradual dose reduction, in the ab- sence of identified and documented clinical contraindications, must be attempted; if they fail, they should be attempted again in ap- proximately 3 months. Include gradual an- tipsychotic medication dose reduction as part of your nursing home’s standard prescribing practice to eliminate or reduce long-term use. Keep in mind that dementia, like any chronic condition, changes over time and that medica- tions and nonpharmacologic approaches should be monitored and adjusted as needed. Involve the resident and family Residents and their families must have a voice Residents with dementia can become anxious, fearful, aggressive, or resistant to receiving care. Try these strategies to reduce behavioral and psychological symptoms of dementia. • Sensory practices: aromatherapy, massage, multisensory stimula- tion, bright light therapy • Psychosocial practices: validation therapy (the practice of validat- ing the individual’s perceived reality and emotional experience to ensure negative emotions aren’t exacerbated), reminiscence thera- py, music therapy, pet therapy, meaningful activities • Structured care protocols: individualized communication and inter- action strategies, technical skills (for example, bathing and oral care). Source: Scales 2018 Nonpharmacologic care approaches (continued on page 14)10 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com Build resilient teams to tackle nursing burnout Use purpose, priorities, perspective, and personal responsibility to create culture-changing teams. By Teresa M. Stephens, PhD, MSN, RN, CNE T AKING Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, the 2019 consensus report by the National Acad- emies of Sciences, Engineering, and Medicine (National Academies), details the latest evidence on burnout and calls for an immediate response. This work follows other recent recommenda- tions for addressing burnout and recognizing it as a public health crisis due to its devastating ef- fects on individuals, organizations, patients, and communities. (Read more about the report in “Leading the way to professional well-being” in the February issue of American Nurse Journal at myamericannurse.com/leading-the-way-to- professional-well-being .) Personal resilience (using personal protec- tive factors to cope with stress and adverse events to enhance well-being and the ability to face future challenges) can help individuals mediate the negative effects of workplace stress and adversity, but we can’t expect indi- viduals armed only with personal resilience to single-handedly tackle the larger systems and cultural issues that lead to widespread burnout, especially in the presence of fear and intimidation. The National Academies rec- ommends a systems approach that includes radical positive disruption and creative prob- lem-solving. This approach requires the com- mitment and courage of a resilient team, com- posed of resilient individuals, dedicated to collaboratively promoting change. Teamwork The Agency for Healthcare Research and Quality in partnership with the Department of Defense developed the TeamSTEPPS curricula (ahrq.gov/teamstepps/instructor/index.html) to improve teamwork within healthcare or- ganizations. This important (and free) pro- gram is based on the evidence that teams (whether they work effectively or ineffective- ly) are directly related to the quality and safety of patient care. In my previous article, “Building personal resilience” (myamericannurse.com/building- personal-resilience), I introduced the 4Ps of resilience: purpose, priorities, perspective, and personal responsibility. The 4Ps also can be applied to developing resilient teams that col- lectively harness their energy, knowledge, skills, and attitudes to transform systems. Building resilient teams To fully grasp the relevance and importance of building resilient teams, we should begin by clarifying two key terms. First, what is a “team”? The TeamSTEPPS curriculum provides a definition that can be applied to both prac- tice and academic settings: “A team consists of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, have specific roles or functions, and have a time-limited member- ship.” Next, let’s apply the definition of re- HEALTHY NURSEMyAmericanNurse.com March 2020 American Nurse Journal 11 silience to teams. Resilient teams can be de- scribed as those that use intentional strategies to cope with challenges, adversity, and stres- sors to successfully achieve goals and objec- tives and to enhance their ability to face future challenges. Think about a successful team that you’ve been a part of or have observed. You may even think of fictional teams, such as those depicted in books or movies. One characteris- tic most of these teams have in common is the uniqueness of the individual team members; they each bring their own knowledge, skills, and attitudes (diversity) to the team to en- hance its ability to meet the desired outcomes. The intentional design of a team is critical to its success. If you have the luxury of building a team from the ground up, the design process will be easier than if you already have a team in place. However, a team using the 4Ps can become resilient with intention, com- mitment, and the essential competencies (knowledge, skills, attitudes) of resilience. Keep in mind that this isn’t a strictly linear process. I encourage you to revisit each of the 4Ps for reflection and revision. Purpose When discussing personal resilience, I usual- ly begin with priorities as the first P, but a team must first establish its purpose before moving through the other domains. Your team’s purpose is your why: Why does this team exist? Why are we here? These ques- tions may seem simple, but many teams have members with different thoughts about the purpose. To avoid confusion, frustration, and conflict, establish a shared mental model of your team’s “why” before beginning or mov- ing forward with its work. This first step re- quires consensus and commitment from every team member. Begin by identifying the problem or issue you want to address. For in- stance, if you’re a member of a search com- mittee, you may decide to focus on recruit- ment and/or retention. Purpose •Why are we here? •Why does this team exist? Priorities Our priorities consist of our organizational and individual values, professional ethics, and desired outcomes. In other words, they’re the goals we want to accomplish, how we want to accomplish them, and how we want to be known or evaluated (our image). Begin by listing your organization’s values (if you’re un- sure, check your organization’s website, where they should be readily available) and use them as a foundation for your team prior- ities. Acknowledge individual values and rec- ognize that generational and cultural differ- ences may exist. After identifying the core team values, determine the team’s desired outcomes and goals; develop them in sync with the team’s purpose. Ensure that everyone has a clear under- standing of expected behaviors. Consensus is best achieved when a high level of trust exists among team members. Daniel Venables, who works with schools to build professional learning communities, recommends establish- ing team norms (common patterns of partici- pation that promote a shared understanding of individual expectations of each team mem- ber). Venables has developed a free tool for developing team norms (access the tool at bit.ly/2tElFqf). You also may want to consider developing a team charter or code of conduct to further establish team norms, especially if you’re addressing a sensitive topic. (See Code of conduct. ) Priorities •What matters to us? Why does it matter? •What are our organization’s values? In- dividual team members’ values? •What are the essential elements of our professional code of ethics? •What are our goals/objectives? (List two or three SMART [specific, measurable, achievable, relevant, and time bound] goals.) •How do we want to be known (our rep- utation within the organization)? •What behaviors will not be tolerated (in- civility, rankism, “abuse of power,” etc.)? Perspective A resilient team needs an informed perspec- tive where behaviors and decisions are guided by facts (evidence) rather than personal opin- ions, cultural norms, and/or precedent. Teams serve to fulfill needs that can’t be fulfilled 12 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com through an individual’s own knowledge, skills, and strengths. To be effective, a team must have the right people in the right seats, and this requires di- versity. Think about the most successful sports teams or musical groups. Each member brings unique skills to perform a specific function re- quired for success. However, no team mem- ber works in isolation. Each individual per- forms his or her roles and responsibilities in sync with other team members and key stake- holders. An informed team perspective begins with a foundation of respect and trust. Members should be chosen based on their “fit” with the team’s purpose and priorities, including their abilities and willingness to share and receive information. They shouldn’t be chosen to sim- ply fulfill the requirements of having a com- mittee without having real roles and responsi- bilities in decision-making. Many organizations use the shared governance model to effective- ly empower and ensure diverse perspectives are heard and valued. Develop your team’s informed perspective and determine the knowledge and skills it needs by identifying what’s known and not known about the problem or issue you’re tackling, including a review of the evidence to identify trends and best practices, as well as any discrepancies in current practice. When possible, seek information from interprofes- sional colleagues from within and outside your organization. Perspective •What do we know about this issue? What have we already tried? •What policies/processes are we using to guide our practice(s)? How do they compare to national trends and/or best practices? •Why haven’t we succeeded in address- ing this issue? What are the bottlenecks, biases, or blind spots? •What are the key elements of this issue? For example, if you’re developing a team to address retention, you’ll want to choose team members with expertise in the issues (work environment, leader- ship, workload, culture, salary/benefits, etc.) known to affect it. (Note: This will require a literature search to identify current evidence.) •Who in our organization is an expert on any of these key elements? •Who outside our organization is an ex- pert on any of these key elements? •Do any professional organizations pro- vide toolkits, white papers, or position statements on this issue? •Who has already successfully ad- dressed this issue? What are they doing differently from us? •Who needs to be on this team to pro- vide an informed perspective to see the bigger picture? •Who no longer needs to be on this team? Personal responsibility Our personal responsibility as a member of a resilient team is centered on our commitment to the previous 3Ps: purpose, priorities, and Use this sample resilient team code of conduct to develop one for your team. As members of this team, we agree to commit to the following code of conduct in all team interactions. 1 I commit to the development of a psychologically safe team envi- ronment where everyone has a shared voice and all issues and con- cerns can be openly discussed without fear of reprisal. This includes my personal responsibility to demonstrate humility, courage, com- passion, a growth mindset, mutual respect, integrity, accountability, and trustworthy behavior. 2 Each team member has an equal voice in all interactions and deci- sions, without deference to rank, title, or tenure (years of service). 3 I agree with the established purpose and priorities for this team. If I find myself in conflict with them, I will share my concerns in a time- ly manner with the entire team. 4 I agree that every member of this team brings value to our purpose and priorities. Therefore, each individual may assume leadership when his or her specific knowledge and skills are needed for guid- ance. I commit to recognizing my own areas of expertise as well as my own limitations, and I am willing to listen and consider evidence that is contrary to my personal opinions. 5 I agree that our team will pursue our goals and objectives through the review of best evidence and practices, which may be contrary to our current policies, processes, and personal opinions. Date: ________________ Team member signatures: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Code of conductMyAmericanNurse.com March 2020 American Nurse Journal 13 perspective. We must be willing to let go of our own personal agendas and egos to fulfill our obligations to the team’s purpose and pri- orities. At times, we may have to make deci- sions that are difficult, even risky. This is espe- cially true when dealing with culture change. We may need to demonstrate moral courage in speaking out against behaviors and practices that have led to unhealthy work environments or broken systems that contribute to nurse burnout. We need to avoid getting caught up in the emotions of these situations and not ap- proach them from a position of anger or judg- ment. Then, with compassionate courage, we can boldly speak the truth without personal at- tacks or actions that harm individuals. Personal responsibility •Who is influenced/affected by my be- haviors, actions, and/or decisions? (Con- sider colleagues, supervisors, subordi- nates, and yourself.) •How am I held accountable for my be- haviors, actions, and/or decisions? (This is especially important for leaders.) •When was the last time I openly changed my mind when presented with evidence contrary to my personal opinion? •When did I last seek advice or wisdom from someone with expertise on the subject before I made a decision? •What are my personal biases and/or blind spots? What would others say are my biases and/or blind spots? •How do I avoid rankism when working within a hierarchical system? •How do I encourage others to openly discuss their concerns or areas of dis- agreement with me? •How would others describe my strengths and weaknesses? How have I respond- ed to this feedback in the past? •Do I value people over policies and processes? Do I value relationships over rules and regulations? •How do I promote a psychologically safe work environment? •How do I want to be known? Is this con- sistent with the feedback I receive from evaluations? If not, what are the discrep- ancies? •What can I do to improve others’ per- ceptions of me? Moving forward safely When facing a problem or issue that’s con- tributing to moral distress or burnout within an organization, carefully assess your own behaviors, potential biases, blind spots, and motives. Then find someone you can trust in the organization who shares your desire to improve the workplace culture. Review this article together and brainstorm how you can begin building a resilient team. If you don’t have someone within the organization you trust, seek the counsel of an outside mentor or colleague. You may recall learning about Maslow’s hierarchy of needs and the importance of feeling safe before we can move to higher levels of self-actualization. The concept of “psychological safety in the workplace” is the focus of Amy Edmondson’s book, The Fearless Organization, which describes the results of her research into effective team dynamics. Edmondson—a leadership, team- ing, and organizational learning expert—de- scribes team psychological safety as a shared belief that the team is safe for risk-taking. Psychological safety in nursing is critically important to promote engagement and re- duce what Edmondson calls the “epidemic of silence” (not speaking out even when we believe we have something important to say). Psychological safety is critical to build- ing resilient teams. Make a commitment to building resilient teams in an environment that provides psy- chological safety. Creating these teams has the potential to radically transform nursing and address burnout. AN Teresa M. Stephens is an associate professor at Medical University of South Carolina in Charleston. References Brigham T, Barden C, Legreid Dopp A, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. Na- tional Academy of Medicine. January 29, 2018. nam.edu/ journey-construct-encompassing-conceptual-model- factors-affecting-clinician-well-resilience/ De Clercq D, Pereira R. Resilient employees are creative employees, when the workplace forces them to be. Cre- ativity and Innovation Management. 2019;28(3):329-42. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. July 5, 2017. National Academy of Medicine. nam.edu/burnout-among-health-care-professionals-a-call-14 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com to-explore-and-address-this-underrecognized-threat-to- safe-high-quality-care Edmondson A. Creating psychological safety at work in a knowledge economy [video]. July 6, 2018. youtube.com/ watch?v=KUo1QwVcCv0&feature=youtu.be Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Inno- vation, and Growth. Hoboken, NJ: John Wiley & Sons; 2019. Edmondson A. Psychological safety and learning behav- ior in work teams. Adm Sci Q. 1999;44:250-82. journals .sagepub.com/doi/pdf/10.2307/2666999 Joseph ML, Bogue RJ. A theory-based approach to nurs- ing shared governance. Nurs Outlook. 2016;64(4):339-51. Jha JK, Pandey J. Spreading the light of knowledge: Nexus of job satisfaction, psychological safety and trust. Int J Knowledge Manag. 2016;12(3):30-47. Maner JK. Dominance and prestige: A tale of two hierar- chies. Curr Direct Psychol Sci. 2017;26(6):526-31. McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nurs Ethics. 2018;25(5):552-70. National Academies of Sciences, Engineering, Medicine. Taking Action Against Clinician Burnout: A Systems Ap- proach to Professional Well-Being . Washington, DC: The National Academies Press; 2019. Savel RH, Munro CL. Moral distress, moral courage. Am J Crit Care. 2015;24(4):276-8. Shanafelt T, Swensen SJ, Woody J, Levin J, Lillie J. Physi- cian and nurse well-being: Seven things hospital boards should know. J Healthc Manag. 2018;63(6):363-9. Sherman RO. Finding your true north. Nurse Lead. 2017; 15(6):370-1. Stephens TM. Nursing student resilience: A concept clar- ification. Nurs Forum . 2013;48(2):125-33. Stephens TM. Building personal resilience. Am Nurs To- day. 2019;14(8):10-5. Stephens TM, Smith P, Cherry C. Promoting resilience in new perioperative nurses. AORN J. 2017;105(3):276- 84. Ulrich CM, Grady C. Moral distress and moral strength among clinicians in health care systems: A call for re- search. National Academy of Medicine. September 23, 2019. nam.edu/moral-distress-and-moral-strength-among- clinicians-in-health-care-systems Venables DR. The Practices of Authentic PLCs: A Guide to Effective Teacher Teams. Thousand Oaks, CA: Corwin; 2011. Weberg DR, Fuller RM. Toxic leadership: Three lessons from complexity science to identify and stop toxic teams. Nurse Lead. 2019;17(1):22-6. White EM, Aiken LH, McHugh MD. Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. 2019;67(10):2065-71. in deciding whether antipsychotics are used. Discuss the risks and benefits of the proposed care and available alternatives. If the medica- tion is prescribed, engage residents and their families in the medication-tapering plan and eventual discontinuation. Recognize that resi- dents or families may fear that reducing or dis- continuing the medication will result in dis- ruptive behaviors. Discuss plans to monitor and support the resident. Experience greater satisfaction and well-being Changing your culture and practice to first use nonpharmacologic approaches to care— rather than antipsychotics—for residents with dementia-related behaviors will take time. Track the use of antipsychotics against your goal. Monitor how well all members of the care team are anticipating and responding to residents’ needs and behavioral expressions. When you identify barriers, assess what additional resources are needed to support staff, residents, and family members. Quality dementia care requires an individ- ualized approach to reduce reliance on an- tipsychotic medications. To determine what works best, assess communication strategies that help staff understand each resident’s needs and observe and measure the resi- dent’s responses to a variety of interven- tions. The data will tell you when you’ve reached your reduced antipsychotic medication goal. You’ll see fewer sedated residents, hear resi- dents interacting with families and staff and engaging in activities they enjoy, and sense less fear. Residents like Joe, as well as his family and staff, will experience greater satis- faction and improved well-being. AN Visit myamericannurse.com/?p=64623 to view a list of references. Kelly O’Neill is a program manager at Stratis Health in Blooming- ton, Minnesota. Marilyn Reierson is a senior program manager at Stratis Health. Kaylie Doyle is a program manager at Telligen in West Des Moines, Iowa. Angel Davis is a health insurance special- ist/nursing home subject matter expert at the Centers for Medicare & Medicaid Services in Baltimore. Jane Pederson is chief medical quality officer at Stratis Health. *Name is fictitious. (continued from page 9)MyAmericanNurse.com March 2020 American Nurse Journal 15 W E ’ RE EXTREMELY FORTUNATE to be mem- bers of a profession that the public considers the most honest and ethical for the 18th year in a row, according to the latest Gallup poll. Patients trust us to provide the clinical care they need. And they count on us to always do the right thing for them and others in their community. What an enormous honor and re- sponsibility. As nurses and community members, we can face an ethical issue at any time. We may find ourselves having to make sure a patient’s end-of-life wishes are honored, to advocate for a safe work environment, or to speak out against acts of racism and discrimination af- fecting individuals and entire populations. It’s this last issue I’d like to address here—not on- ly because of the rise of uncivil and hateful speech and actions, but also to reemphasize our ethical duty to speak out. One of our fundamental guides, the Amer- ican Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements, clearly states that nurses must practice with respect for the dignity, worth, and unique attributes of all our patients. To do this, we must identify and set aside our biases or prejudices so we can build trusting relationships with patients and provide the best care that everyone de- serves. We also can find ourselves on the re- ceiving end of racism and discrimination as we go about our practice, which is something I personally experienced during my career. All of us are shaped by our cultures and personal experiences, but I have no doubt that nurses do their best to follow our Code and to navigate ethical issues at the bedside and in other practice environments. However, the Code also speaks to our larger role and re- sponsibility in the areas of human rights, so- cial justice, and disparity reduction. So, I’m asking you to go beyond your practice set- tings to advocate more broadly, if you aren’t already. I think it’s crucial that we all stand up and speak out against racism, discrimination, and prejudice whenever and wherever it oc- curs—workplaces, communities, and the po- litical arena. We may believe our voices and actions can’t possibly matter in the face of such deeply entrenched societal issues and beliefs. And it takes courage. But this phrase comes to mind: Trees grow from the roots up. One pos- itive action by one person can lead to many more people working for the rights of all. The Year of the Nurse campaign and National Vol- unteer Week (April 19-25) provide us with the perfect platforms to strengthen our advocacy. Consider starting a group, or volunteering in one, that addresses discrimination, preju- dice, and other social justice issues—including social determinants of health—in your work- places, communities, and professional asso- ciations. Raise these same issues with political candidates and other policymakers and hold them accountable. Again, our Code can help guide you in these conversations, as can the ANA Center for Ethics and Human Rights, which is celebrating its 30th anniversary this year. The center has many powerful re- sources, including a position statement and an educational video on nurses’ roles in address- ing discrimination, that can help you in this vi- tal work ( tinyurl.com/ycewzp42 ). Together, we can grow a world where so- cial injustice, incivility, racism, discrimination, and prejudice against anyone—because of their faith, gender, color, ethnicity, or other characteristic—will not be tolerated. And I be- lieve in the power of nurses to lead that change. Ernest J. Grant, PhD, RN, FAAN President, American Nurses Association Nurses and the public’s trust Speaking out against racism, discrimination, and prejudice PRACTICE MATTERS From your ANA President One positive action by one person can lead to many more people working for the rights of all.16 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com Adults with chronic kidney disease: Overview and nursing care goals Gain the knowledge to care for these patients confidently. By Jennifer Chicca, MS, RN, CNE-cl L EARNING O BJECTIVES 1.Identify causes and risk factors for chronic kidney disease (CKD) in adults. 2.Describe the diagnosis of CKD. 3.Discuss three nursing care goals for patients with CKD. The author and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit. Expiration: 3/1/23 CNE 1.36 contact hoursMyAmericanNurse.com March 2020 American Nurse Journal 17 A PPROXIMATELY 30 million American adults have chronic kidney disease (CKD), an ad- ditional 20 million are at risk for developing it, and a variety of factors (such as the per- vasiveness of obesity and chronic health conditions) may increase its incidence. Nurses will continue to encounter patients with CKD in all practice settings, where they will help manage the disease and pre- vent progression. This article provides an overview of CKD in adults and care goals for nurses who want to ensure that they can help meet the needs of patients with CKD. (Visit myamericannurse.com/?p=64618 for an overview of kidney function.) Overview CKD is a structural and/or functional abnormal- ity of the kidney that lasts 3 months or longer. It’s a progressive and chronic condition that affects many aspects of the patient’s health. Common causes and risk factors The top three causes of CKD (in order of in- cidence) are diabetes, hypertension, and glomerulonephritis. Diabetes and hyperten- sion cause approximately 70% of CKD cases. Other risk factors include: •congenital abnormalities (for example, poly - cystic kidney disease, Alport syndrome, sick- le cell disease) •urinary tract or systemic infections •family history of CKD •urinary or kidney stones •history of acute kidney injury or failure •urinary tract obstruction •autoimmune disease (for example, sclero- derma, systemic lupus erythematosus) •nephrotoxin exposure from sources such as over-the-counter pain medications (for example, aspirin or ibuprofen), prescribed pain relievers (for example, oxycodone or naproxen), other medications (for exam- ple, antibiotics or antineoplastics), pesti- cides, and heavy metals (for example, lead, mercury, or arsenic) •age 60 or older and ethnicity (African American, American Indian, Asian, Pacific Islander, or Hispanic). Early-stage CKD can be asymptomatic, so recognizing risk factors and alerting patients and providers to them is crucial for preven- tion, early diagnosis, and optimal disease management. Diagnosis In the past, CKD diagnosis was based on serum creatinine results. However, recent evidence suggests that’s not an accurate measure because of variations in patients’ body size, weight, and muscle mass. Now, CKD is diagnosed based on glom erular filtra- tion rate (GFR), which is a calculated value that takes into account body size, weight, and muscle mass and includes modifica- tions for ethnicity. GFR is automatically cal- culated and reported by laboratories as part of serum results (for example, as part of a comprehensive metabolic panel). Labs cal- culate the rate using the Modification of Diet in Renal Disease or the Chronic Kidney Dis- ease Epidemiology Collaboration formulas. Other tests, such as urinalysis and serum re- sults, also are important in CKD diagnosis and management. For example, a provider may find that a patient has decreased serum hemoglobin and hematocrit values that re- quire prescribing a synthetic erythropoi- etin, such as epoetin alfa. (Visit myamerican nurse.com/?p=64618 to view a list of CKD di- agnostic tests.) Staging and symptoms As with many chronic diseases, trended data (or data collections over time) can be used to help manage CKD. Typically, interven- tions are planned based on CKD stage and how a patient feels physically and mentally. Stage is determined mainly based on GFR and the presence of kidney damage. (See CKD staging.) Due to the kidneys’ compensatory abili- ties, symptoms occur gradually and may not become obvious until CKD is advanced. In earlier stages (1 to 3), patients may be asymptomatic or have subtle, nonspecific symptoms that are attributed to other condi- tions. By the time patients experience overt symptoms (stages 3 to 5), typically 80% to 90% of kidney function has been destroyed. (Stage 3 CKD may be considered early or late depending on many factors, including diagnostic test results and how a patient feels.) (See CKD symptoms.) Complications CKD complications include heart failure, hy- pertension, hypervolemia, arrhythmias, ane- mia, pulmonary edema, anorexia, seizures, Provide patient- specific education to help patients take charge of their condition and promote well-being.Next >