The Importance of Supporting Mothers Who Breastfeed

by Rachel B. Barrientos, Student Nurse, and Paula Bylaska-Davies, RN, MS, Assistant Professor, Massachusetts College of Pharmacy and Health Sciences

rachel.barrientos@my.mcphs.edu 

Breastfeeding has always been an important part of infant health; around the world mothers have been breastfeeding their children since the beginning of the human race. The American Academy of Pediatrics recommends that children are nursed for at least the first 12 months of life. Furthermore, the World Health Organization recommends an even longer period of 2 years (CDC, 2010). According to the Centers for Disease control, only 22.7% of infants born in 2006 were still at least partially breastfeeding at 1 year of age (CDC 2010).

There are many health benefits to breastfeeding children such as lower mortality rates, ideal nutritional values, and long term benefits such as healthy weights and higher intelligence later in life. The positive aspects of breastfeeding extend to maternal health as well, such as lower rates of breast and ovarian cancers and decreased occurrences of post-partum depression. Nurses play an important role in encouraging and supporting breastfeeding; they have multiple interactions with the mother during pre and post-natal appointments where they can advocate for breastfeeding through teaching.

Breast milk is the ideal source of nutrition for growth and development, providing newborns and infants with nutrients in natural forms. The longer a child is breastfed the better the results; cessation of breastfeeding before six months increased the risk of pneumonia, doubled the risk of recurrent otitis media, and resulted in higher urinary tract infections in female babies. Long term benefits of breastfeeding were found to include lower blood pressure and cholesterol levels, as well as higher performances on intelligence tests (Bai, Middlestadt, Peng, & Fly, 2009). Potentially, 1.3 million lives can be saved each year by mothers that continue to breastfeed beyond six months (Bai et al., 2009). It is also reported that “early cessation of breastfeeding increases infants' risks for childhood obesity, gastroenteritis, necrotizing enterocolitis, leukemia, otitis media, severe lower respiratory infections, sudden infant death syndrome, and types 1 and 2 diabetes” as well as incurring an average of $475 more in health costs in the first year than those infants exclusively breastfed (Bartick, Stuebe, Shealy, Walker, & Grummer-Strawn, 2009).

The maternal benefits to breastfeeding include lower risk for breast and ovarian cancers, type 2 diabetes, and postpartum depression for mothers that breastfed their infants (Bartick et al., 2009). Emotionally, mothers benefit from breastfeeding by forming a stronger bond with their baby. A research study reported that the number one advantage of breastfeeding stated by mothers was “helping bond with baby” (Bai et al., 2009).

Early cessation of breastfeeding is identified by the Department of Health and Human Services as a problem. A goal included in Healthy People 2010 and again in Healthy People 2020 aimed to increase the proportion of mothers who breastfeed their babies ever, at six months, and at one year (U.S Dept. of Health and Human Services, 2010). Despite frequent contact with health care professionals, the first two weeks of life require increased breastfeeding education and support, as this is when breastfeeding has a high cessation rate (Bartick et al., 2009). Identifying factors that affect cessation of breastfeeding will aid in increasing maternal support and in turn increase child and maternal health.

Out of all healthcare providers, nurses spend the most time with mothers during the pre and post-partum period, as well as care for the infants following delivery. Bartick et al. (2009) reported that the nursing staff at “88% of facilities reported that they taught most mothers techniques of breastfeeding...” However, 65% advised women to limit suckling, 45% gave pacifiers to healthy infants, and 24% regularly gave milk supplements to the majority of healthy infants (Bartick et al., 2009). Nurses can encourage the advancement of breastfeeding by increasing breastfeeding teaching to 100% and decreasing detrimental practices such as limiting suckling, pacifier use, and formula supplements. In addition, nurses can provide better teaching and positive support before birth and after hospital discharge; “...data suggested that many women had never even considered breastfeeding and often discontinued breastfeeding due to discomfort, embarrassment, and lack of assistance” (Flower, Willoughby, Cadigan, Perrin, & Randolph, 2007).It is important for nurses to explore the positive and negative aspects of breastfeeding from the mother's perspective. The most frequently reported benefit from breastfeeding mothers was the emotional bond with the infant formed while breastfeeding (Bai et al., 2009; Wambach & Cohen, 2009). The other advantages reported in studies were contributing to the health of the infant, experiencing convenience of breastfeeding, and saving money (Bai et al., 2009, Wambach & Cohen, 2009). One of the negative aspects of breastfeeding reported by women had to do with nursing in public, some women had difficulty finding a place to nurse in public as well as experiencing some embarrassment when nursing in public (Bai et al., 2009, Wambach & Cohen, 2009). By advocating for more private breastfeeding

spaces in public areas, nurses can help to reduce one of the major factors behind cessation of breastfeeding.

Factors related to initiating breastfeeding have been explored by many researchers (Barona-Vilar, Escriba-Aguir, & Ferrero-Gandia, 2007; Flower et al., 2007, Wambach & Cohen, 2009). Demographics play an important role in the decision process for a pregnant woman (Barona-Vilar et al., 2007; Flower et al., 2007). Women were more likely to initiate breastfeeding if they were educated, married or had a first-born child (Flower et al., 2007). However, women who returned to work at two months or received WIC were less likely to initiate breastfeeding (Flower et al., 2007). Social support also plays a role in a woman's decision to initiate breastfeeding, women in higher socio-cultural groups relied on the support and opinions from their partners and healthcare networks, whereas women who were from lower socio-cultural groups reported friends opinions and support was influential on whether to initiate breastfeeding (Barona-Vilar et al., 2007). In order to increase support for new mothers, nurses can extend patient teaching not only to the mother, but to the fathers and other support systems important to the mother. Brochures and literature highlighting the health and financial benefits of breastfeeding should be distributed to women to share with any family members who are unable to attend appointments.

The common reasons reported for stopping breastfeeding before 8 weeks postpartum included insufficient milk supply, latch problems, personal reasons, returning to work and medication use/illness of mom or baby (Lewallen et al., 2006). In addition, pain, nipple soreness and embarrassment related to public breastfeeding were stated as reasons for discontinuing breastfeeding before 6 weeks postpartum (Wambach & Cohen, 2009). Prenatal teaching regarding proper techniques should prepare new mothers as to what to expect when breastfeeding, as well as at the follow-up at well-baby visits to address additional issues that may arise. This additional support may increase the longevity of breastfeeding mothers by resolving complications if they arise.It is necessary for nurses to encourage and support breastfeeding during interactions with mothers. Nurses should address the discontinuation of breastfeeding by teaching mothers pre and post-partum how to avoid the pitfalls behind cessation of breastfeeding, such as pain, discomfort, frustration, lack of support, and the public’s disapproval. This teaching would include assisting mothers with proper latch techniques and encouraging mothers to participate in breastfeeding classes pre-natally as well as breastfeeding support groups during the post-partum period. Mothers should be taught how to pump, store, and prepare breast milk as they may re-enter the work force following maternity leave, as well as reinforcing the benefits of breast milk at well baby visits to encourage the continuation of breastfeeding. Nurses can also advocate for improved breastfeeding areas for mothers and infants in public areas and the workplace. By increasing

patient teaching as well as educating the public, the numbers of mothers who initiate breastfeeding as well as the longevity of breastfeeding by mothers will increase, ultimately improving child and maternal health and decreasing healthcare costs.

 Automated employee scheduling: Welcome to the futureNursing Management

The healthcare industry is appropriately renowned for its breathtaking pace of innovation in so many important areas. Cutting-edge treatments, breakthrough discoveries, and dramatic progress in disease prevention, infection control, and other aspects of patient care have helped this nation's healthcare system maintain its status of excellence around the world.

In recent years, though, as systemic costs have exploded, the industry's focus has widened to encompass not only the quality of patient care itself, but also the underlying infrastructure, methods, and costs of the care delivery processes. In many ways, the healthcare industry has fallen short of its goals of efficiency, cost-effectiveness, and timeliness. Nurse executives are constantly challenged with meeting all three objectives due to the staffing schedules they must create and maintain. The fact is, despite all of the fancy devices, tests, treatments, and equipment in units, departments, and labs, innovation and technology have largely failed to reach the nurse manager's office when the time comes to devise the monthly or biweekly schedule.

Case in point

BayCare Health System, a community-based organization in the Tampa Bay, Fla., region, features 10 not-for-profit hospitals and approximately 200 other locations (such as outpatient facilities, clinics, labs, and offices). BayCare employs approximately 17,500 people, including more than 4,000 nurses. With such a broad workforce distributed across multiple facilities, there was a high degree of variance in scheduling procedures, some of which were paper-based. Due to this detachment, each department had its own rules and processes for scheduling.

In effect, each location was its own "island." There was no fluidity to the scheduling process, which created numerous costly inefficiencies. For instance, it wouldn't be uncommon for a nurse to-with the best of intentions-"hide" another nurse in the schedule or have people on-call to protect against unplanned staffing shortages. Schedulers couldn't see the basics--who, what, where, and when, which created several challenges. First, it left the facility vulnerable to costly contract labor and overtime charges that, with better planning, could've been avoided. It also created staff-mix issues. Some days, the team was heavily skewed to numerous graduate nurses with less experience, forcing a shuffle of the deck to rebalance staff by transferring people to other departments. Other times, there were too many nurses because schedulers simply didn't know who was coming in. The "house supervisor" nurse would look at the schedule every day at 5 a.m. and decide who would need to float to which unit, when to call in more people, and when to send some home early.

Naturally, nurses didn't hold this unreliable system with very high regard, which may have contributed to a higher-than-desired annual turnover rate of 11%. It was difficult to achieve regularity in the schedule, so nurses always struggled with constantly changing shifts. Staff members called in on emergency were often sent home without working, and with a level of variability that sometimes seemed arbitrary, there were times when perceptions of favoritism were abundant.

Of course, these manual methods were also time-intensive. Nurse managers spent anywhere from 4 to 24 hours on manual scheduling. This work distracted from patient satisfaction, clinical outcomes, mentoring, and more. As BayCare was preparing to launch a broad electronic medical record initiative, managers needed to be out on the floors and in the departments, not stuck behind a desk, buried in paper schedules.

A time for change

In 2008, manual methods were hindering BayCare's efforts to reduce costs and improve nursing satisfaction. Although scheduling difficulties hadn't materially impacted patient care, they created too many obstacles for nurses and nurse managers. The tipping point arrived when staff began working with a healthcare operations consultancy. They were advocating

processes based on free scheduling, transparency, and fluid staffing--but BayCare didn't have the technology or information needed to make that happen.

BayCare had previously implemented an enterprise-wide time and attendance solution and, based on the success of that system, approached the same vendor for workforce management and scheduling analytics. A liaison at each hospital activated one or two units at a time. This took place across the entire BayCare system. In less than 18 months, more than 90% of nursing departments were up and running with the new system.

Although different departments had varying needs, it generally took about 3 months to bring a unit online from "start to live." The Information Systems team was indispensable in this process, working to build background rules regarding the number of paid-time-off requests allowed, weekend rules, and other parameters. The biggest paradigm shift for nursing staff was that the schedule now started with "employee self-service."

Was the changeover from manual to automated electronic scheduling trouble-free? Not always. There were pockets of uncertainty and concern given the potential for disruption. BayCare started with one of its hospital's respiratory units: the biggest in-patient unit for full-time equivalent nurses. Next, the technology launched in the float team pool, essentially making floaters "missionaries" for the new system. When their peers saw how float nurses requested their own shifts, it created a pull effect and raised the anticipation for their own units to adopt the new scheduling system.

When that first schedule came out, there was certainly a palpable anxiety among the staff members, who were wondering about the impact on their own shift preferences and lifestyle. But with careful preplanning and explanations that no one would endure a "bad" schedule, the many benefits of this new approach quickly became apparent.

Using the web application, a nurse can request his or her upcoming schedule with just a few mouse clicks-a huge improvement over manual requests. Requesting PTO is also just as easy. These tasks have near-zero impact on the workday, as requests can be entered remotely. Nurses can also express their preferences for "float" positions or willingness to be "called off" first. Not surprisingly, after the first schedule, the nursing team's initial concerns disappeared quickly. Virtually every unit has experienced 100% compliance from its nursing staff.

For the better

For nurse managers, automated scheduling represents a dramatic reduction in administrative burdens. For example, BayCare has reduced its scheduling time from 8 to 12 hours to just 2 hours every 4 weeks. Managers across all units report similar productivity improvements. From a contract-labor perspective, the new system has had a tremendous impact. In 2008, BayCare's expense for contract labor and traveling nurses was $2 million. Today, that number is zero, as the organization relies on its own internal float team to meet any staffing shortages.

The larger impact has occurred out on the unit floors across BayCare's 10 hospitals. With the new scheduling system, BayCare achieved a level of transparency that's without precedent. Managers can locate which departments are "working short" and which have too many nurses. They can see a few days into the future and identify departments that are significantly short and adjust the staffing plan. Now, managers are accountable for balancing the schedules with the appropriate mix of skills and seniority. Another advantage is that

these schedules are visible to everyone, creating a subtle but important pressure for nurse managers to get things right.

Proper schedules are extremely helpful at BayCare. As a Florida-based health system, it experiences wide seasonal swings in patient volumes. There are spikes in patient visits during winter months, as the "snowbirds" come to the Tampa area. Also, usage patterns change as inpatient volumes ebb and outpatient volumes increase. All of this calls for a far greater level of flexibility in scheduling, one that can adapt every few hours (if necessary), as opposed to a weekly recalibration. For instance, if a manager needs to cut a shift, he or she first targets nurses working overtime. Then, the manager moves nurses from the float team elsewhere.

Attendance is another key issue for virtually any nursing staff manager. One or two unplanned absences can ripple through a shift and create havoc. A suboptimal schedule can contribute to that problem because it conflicts with a nurse's needs, almost inviting him or her to call in sick when those conflicts can't otherwise be resolved. Many of BayCare's departments have seen absences decrease by as much as 20%. Not only does that mean lower overtime costs for nurses to cover those vacancies, it also means a greater consistency in clinical care. Nurses know who they're working with and can function more cohesively with smoother clinical processes.

Job satisfaction has increased for nurses at BayCare. If there's one thing a nurse doesn't like, it's an inconsistent schedule with unplanned changes. After arranging other elements of life (such as child care), no one wants to report to work as planned only to be told they won't be needed that day and to return home, without pay. Through both new software and smarter processes, BayCare now has a better option than "Go home." The organization has reduced the sizes of its on-call float team, reduced staffing shortages, and reduced unnecessary overtime.

This new scheduling system was a unique opportunity for BayCare to embrace meaningful change. It was a catalyst to review processes and leverage innovative software to reduce the steps needed to create effective schedules. Thanks to this new organizational tool, talented nurses can focus less on administrative tasks and more on delivering excellent patient care.

Is It Ethical for a Medical Practice to Dismiss a Family Based on Their Decision Not to Have Their Child Immunized?

Abstract

ABSTRACT: The parents' decision not to have their child immunized stirs up much controversy in the public sector and in the healthcare arena. Much debate surrounds not just the parents' choice but also the practitioner's decision to refuse care based on their refusal. This article presents a common and increasing scenario faced in pediatric practices and explores the ethical implications that it poses for the healthcare provider.

A mother brings her 12-month-old child in for his scheduled well child examination. The physician updates the child's history, reviews the developmental milestones, conducts the physical examination, and provides anticipatory guidance to the mother. Upon completion of the examination, he states that his nurse will be coming in shortly to administer the scheduled 12-month immunizations. The mother states that she and her husband have opted to withhold the varicella vaccine and that they have decided to delay the measles, mumps, and rubella (MMR) vaccine. The physician inquires as to why they have made this decision. She explains that they have researched all the rationale for the vaccinations and the implications of not receiving them. She and her husband question the necessity of the varicella vaccine. As for the MMR, the mother states they wish to delay this immunization to a later date. Their concerns regarding the MMR stem from the autism controversy because 2 of her siblings have autistic children. She states that she knows that the research has shown no linkage. However, based on her family history, she and her husband would feel more comfortable with delaying the MMR. The mother states that she and her husband want their child to receive the MMR but not until he has developed more cognitively, in particular with language skills. The physician presents the rationale for the immunizations and attempts to alleviate her concerns regarding the association between MMR and autism. A lengthy conversation ensues between the physician and the mother, with each providing his and her rationale for and against the withholding of varicella and the delaying of the MMR. In the end, the physician states that if she and her husband decide to not have their child immunized according to the Center for Disease Control vaccination schedule, they will be dismissed from his pediatric practice.

The discussion surrounding immunization compliance among the general population is an ongoing issue in public health; however, it has only been in the last few years that some medical practices are responding to this by dismissing a family for refusing immunizations for their child. A survey conducted by the American Academy of Pediatrics (AAP) regarding immunization administration reported that 85% of pediatricians experience parental refusal of some or all vaccinations annually.1 In 2005, a study was conducted by Flanagan-Klygis et al,2which looked at pediatricians' attitudes regarding dismissing the family who refuses vaccines. Their study results showed that 40% of pediatricians reported that they would no longer provide care to a family that refused all vaccines and that 28% reported that they would not provide care to a family that refused select vaccines. In a clinical report issued by Diekema and the AAP Committee on Bioethics,3 pediatricians stated that this dismissal would be deemed necessary if the parents continued with immunization refusal despite their attempts to address their concerns and their educational efforts regarding vaccination necessity.

Legal concerns have been cited by practitioners as one of the reasons for a family's dismissal from a practice.4 Healthcare providers are fearful of the potential legal repercussions should an unimmunized child contract the disease, which could have been

prevented through the scheduled vaccination protocol.5 To thwart this potential liability, several practices have implemented a refusal to vaccinate form. This form was designed by the AAP as a template for individual pediatric practices. The form has the parents select which vaccines they wish to defer. It further states that the parents are aware of the vaccine's purpose, risks, and benefits, as well as the consequences of immunization refusal. Parents are then asked to sign that they accept that they may be endangering the health of their child as well as the health of others, if their child should contract the disease.6

Ethical and public health issues have also been raised by practitioners regarding their decision to dismiss a family from their care. The ethical concept of justice has been cited as a guiding principle behind their decision for dismissal. The principle of justice is the belief that risks and benefits be equally distributed among society and that a public health benefit is obtained when an individual is immunized. Using this school of thought, unimmunized children are considered to be "free riders." This is the belief that individuals who are not immunized are taking advantage of the benefit of herd immunity from others who were immunized.3Additional arguments identified for a family's dismissal were a perceived lack of trust in the healthcare practitioner and a lack of shared belief and commitment to the standards of medical care for children.2

The decision for a healthcare provider to dismiss a family for not complying with the ascribed immunization schedule is in direct opposition to the deontological theory. This theory is the belief that our actions are based on our duty in doing what is right. A central tenet of this theory is to treat every one good because it is the right thing to do and that no individual is to be sacrificed for the well-being of others.7 However, this is what is being done when a healthcare provider dismisses a family; they are compromising the health of that family. In addition to the implications found with deontological theory, this decision by a healthcare provider compromises the bioethics principles of autonomy, beneficence, and justice.

The principle of autonomy is being directly challenged in this situation. Autonomy is the right for an individual to make a choice freely without any outside influence, which could be considered forceful in nature.7 In this case, a parent is deemed as the decision maker for the welfare of his/her child. A questionable form of coercion is being exercised by the provider when a family is told they will be discharged from the practice if they do not comply with the immunization schedule. A study was conducted regarding the reasons why some parents changed their minds regarding immunizations after previous refusal. The results showed that 10% of parents reported that they changed their minds because their healthcare provider stated that he/she would no longer care for their child if they did not comply.8 Also the use of a refusal to vaccinate form raises ethical concerns. This form asks parents to sign that they acknowledge that they are endangering the health of their child as well as others by their refusal.6 This is essentially saying that a parent is being negligent in the care of his/her child. In addition to this, the form is in direct opposition to the legislative process that has deemed vaccine exemptions as not posing a significant risk to the child or to others.9 The principle of beneficence is being compromised when a practitioner denies medical care for noncompliance with vaccinations. Beneficence, meaning helping others, is considered a principle as well as a virtue that should be attained by all healthcare providers.7 A denial of healthcare services is not helping a family, only abandoning them. When a family is dismissed from practice for vaccine refusal, they may experience difficulty in locating another healthcare provider. This potential difficulty will affect the family's access to care, making them vulnerable to healthcare disparities.4 Lastly, the principle of justice is in question. This means that a healthcare provider treats all patients equally free of any biases despite an individual's race, gender, income, sexuality, and personal choices.7 A decision that is not in agreement with a provider should not preclude an individual or a family from receiving care.

In evaluating this ethical issue, the American Nurses Association Code of Ethics for Nurses With Interpretive Statements does not have a stated position; however, there are basic principles that address components underlying this ethical issue.10 The first provision discusses the nurse's role in professional relationships. Provision 1.1 and 1.2 states that nursing practice is to be respectful of all individuals, their rights, as well as individual differences without any personal biases. A parent's decision to refuse or defer immunizations is a personal choice, which should be respected despite any differing opinions. Provision 1.4 discusses the right to self-determination, meaning individuals have the right to determine their plan of care. This provision also addresses the nursing role in educating patients in ensuring that they are informed as well as supporting them through the decision process. As a healthcare provider, nurses have a key role in impacting parents in their decision regarding immunizations. By communicating with a vaccine-hesitant parent in a nonjudgmental manner, the nurse can elicit his/her concerns as well as show respect for his/her desire to protect his/her child. It is from this history taking that the nurse can work cooperatively with the healthcare team to educate the parents regarding vaccine safety and attempt to alleviate their concerns. Research has shown that more than 35% of parents who have decided to have their child immunized after previous vaccine refusal cited the educational information and support received from their healthcare providers as their reason for their decision change.8

Another provision in the American Nurses Association Code of Ethics that is challenged with this ethical issue is Provision 2.10 This provision states that the nurse's sole concern is the patient. The word patient is defined as a person, family, group, or a community. Provision 2.1 further addresses how this commitment transcends into the formulation of the patient's plan of care. It states, "The nurse strives to provide patients with opportunities to participate in planning care, assures that patients find the plans acceptable and supports the implementation of the plan."10 Ongoing discussions regarding parents' concerns regarding immunizations and providing information addressing their specific concerns will promote a decision-making relationship between the parents and the healthcare providers. Research has shown that when patients are involved in the decision-making process, they express satisfaction with their healthcare provider, demonstrate compliance with their treatment regimen, and recommended preventative services.11

The decision of a healthcare provider to dismiss a family for refusal of immunizations challenges the basic bioethical principles of autonomy, beneficence, and justice. The family that refuses vaccines should receive the same respect, support, and compassion as other patients who show hesitance toward medical advice. Family dismissal severs the relationship between a healthcare provider and a family and has the potential to negatively impact the family's future choices in obtaining primary preventative services. Dismissing a family is not the best public health strategy. It will not get a child vaccinated or allow for preventative counseling should there be an exposure to a vaccine-preventable disease in the future. Once a family is dismissed, all lines of communication have been severed and any attempts to educate and potentially change a parent's decision have been lost. For this reason, despite the Center for Disease Control's and the AAP's support of universal immunization, these organizational bodies strongly recommend that a family that delays or refuses immunizations should not be dismissed.1 A parent's choice to refuse immunizations is a challenge that should be met by the healthcare provider, not avoided.

Culturally Competent Nursing in HomecareMeghan Crivello, BS, RN, BSNmcrivello1@worcester.edu

Abstract:

Homecare nurses must be culturally aware in order to appropriately care for homecare patients. Culture plays a part in the care of all types of patients but it plays a more important role in homecare. The care is being completed in the home where the patient controls the care. The nurse has to assess the cultural background of the patient in order to implement an appropriate plan of care.

Every day the population of the United States is becoming more and more diverse. It is important for nursing to becoming culturally competent to take care of the patients effectively. It is especially important in home care due to

the fact the care is taking place in the patient’s home. The nurse is essentially a guest in the patient’s home. In traditional health care setting, the patient is the one who could be seen as the guest; in home care it is reversed. Patients have the right to refuse care from the nurse, they control whether they are compliant with the nurses instructions or not. Although this can also happen in a hospital, a homecare patient is able to completely refuse any time of care. A hospitalized patient is at least able to hear what the nurse has to say before deciding not to follow the recommended plan of care. A homecare patient can refuse to even speak or allow a nurse to come into their home. A home care nurse has to be culturally competent in order to be an effective care taker. A patient who may be seen as noncompliant may just have different health care practices based on their cultural. These differences need to be recognized and embraced for the patient to effectively participate in their plan of care. The homecare nurses have to be able to adjust their care accordingly. Prior to becoming culturally competent, the nurse must first look at their own beliefs. The nurse has to understand their own cultural needs before they can take of others.

Registered nurses are primarily Caucasian, 90% compared to 2% of Hispanic registered nurses.(Maier-Lorenz, 2008) Hispanics are the fastest growing minority in the United States, according to the 2010 United State census the Hispanic population grew 43% from 2000 to 2010. The Caucasian population grew only 5.3% in those same ten years.(U.S. Census Bureau, 2011)Homecare nurses have to be culturally competent in their daily care. They have to adjust their plan of care for each patient identifying particular cultural characteristics to meet the healthcare goals for the patient. (Maier-Lorenz, 2008)Madeleine Leininger defines cultural based care in nursing as “the most comprehensive, holistic, and particularistic means to know, explain, interpret, and predict beneficial congruent care practices. Culturally based caring is essential to curing and healing, as there can be no curing without caring, although caring can occur without curing.” (Leininger, 2002) A homecare nurse needs to look at the whole picture of the patient, beyond the medical diagnosis to be an effective caregiver.

To be an effective nurse leader in home care, one has to be aware of what is going on behind the nursing care and especially when the nurse is not there. The nurse needs to be able to determine why a patient may not be receptive to teaching, taking their medications or going to the doctor. The nurse needs to be culturally competent and this can be done by having an open mind. To address the cultural issues up front and ask what can be done differently and what is culturally acceptable.

Language barriers can present a problem. An official translator needs to be available via phone to communicate effectively with the patient. Family members should not be used as translators because they may not translate exactly what is being said. The family member may also include their

personal and cultural preferences in the translation causing a miscommunication between the patient and the nurse.

Madeline Maier-Lorentz identified three steps to provide culturally competent care, adopting an attitude that promotes transcultural nursing care, developing an awareness of cultural differences and performing a cultural assessment.(Maier-Lorenz, 2008) To develop an attitude to accept transcultural nursing care, there are four major components; caring, empathy, openness and flexibility. A nurse is able to demonstrate caring by her approach to each patient and the time she takes to listen to a patient’s specific needs. By taking the time to discuss cultural preferences the patients will become confident in the care they are receiving. Therefore creating better health outcomes. The nurse needs to view the patient’s problems from their cultural perspective to show empathy. This allows the patient to know their cultural beliefs are respected and considered in their care. Openness of the nurse allows the patient to see the acceptance and understanding by the nurse of different cultural practices. Lastly, the nurse needs to be flexible and able to accommodate the specific cultural needs of the patient into the plan of care. These four characteristics show patients their care is individualistic. (Maier-Lorenz, 2008) The nurse needs to develop awareness of cultural differences by understanding that even patients within the same culture may have different opinions and expectations. No two patients are the same; each case needs to be handled individually. While completing a medical assessment on a patient, the nurse also has to complete a cultural assessment. The nurse needs to understand what foods are considered healthy, ones that are eaten in times of illness, whether the patients believes in traditional or alternative medicine, their perception and definition of pain and pain control. It is also important for the nurse to understand the family structure and how that impacts the patient’s plan of care. (Maier-Lorenz, 2008)

While taking care of homecare patients, the nurse has to take into consideration the setting in which they are providing their care. Patients who receive care in their homes need special and different attention than traditional hospital patients. Patients will be receiving most of their care from their family members and primary caregivers, not nurses, doctors and patient care assistants. The nurse only has control during the time in which he or she visits and even then, the patients commands the control. The nurses needs to first understand her own beliefs and views of his or her own culture. After the nurse completes a personal cultural assessment, it is important to complete the patient’s control assessment as part of the admission process to home care. The nurse needs to ask if there are any specific considerations to be aware of, things that will impact the plan of care for the patient. If the nurse is up front with these questions, the nurse will then be able to create an individual plan of care for each patient so each one gets the best possible care. If the nurse does not share the same views, he

or she needs to be accepting, respectful and adjust accordingly. Ultimately, it is up to the patient if they want to receive the home care services so it is the nurse’s responsibility to meet their needs to continue the service.

Family members and primary care givers are essential the health and recovery of the homecare patient. They need to be acknowledged and accepted as part of the plan of care. If they do not agree with the plan of care, the chances they will enforce it for the patient goes down significantly. It is a team effort to achieve the goals of the patient in home care; everyone has to be in agreement. It is the nurse’s job to make sure he or she understands the role the family members play and why.The primary caregiver may not be viewed as someone the nurse would pick as the primary caregiver but it the nurse’s job to accept and plan accordingly.

The homecare nurses need to look at their own personal and cultural beliefs before taking care of homecare patients. Then he or she will be able to accurately assess and accept the patient’s cultural beliefs into the plan of care. The homecare nurse will have to continue to reexamine his or her cultural beliefs as it is an ongoing process. Cultural practices are a very important aspect of healing for patients and are essential for positive homecare outcomes.

TO GOWN OR NOT TO GOWN? FOR MRSA PREVENTION THAT IS THE QUESTION. WHAT IS MRSA?

by Amanda Zapka, SNCo-author: Paula Bylaska-Davies, BSN, MSNMassachusetts College of Pharmacy and Health Sciences

amanda.zapka@my.mcphs.edu

  Methicillin-resisitant Staphylococcus aureus (MRSA) is a staph infection that has become resistant to the beta-lactams antibiotic group, such as methicillin and other penicillin related medications. This antibiotic resistance can make MRSA a difficult infection to treat. In hospitalized patients, MRSA tends to be a life-threatening infection because of prolonged hospital stays, immunocompromised states, and invasive procedures. It can be spread through close skin to skin contact or from items that came in contact with the infection. In the hospital setting, MRSA is generally spread from the unclean hands of health care workers and the improper cleaning of shared equipment. Therefore, it is especially important that healthcare workers follow infection control policies and proper hand washing techniques to prevent the development and spread of MRSA (CDC, 2010).

WHAT IS RECOMMENDED?

The Center for Disease Control (CDC) states that standard precautions should be used for all patients and should be enough to prevent the spread of most MRSA cases. However, in acute-care settings the CDC recommends additional contact precautions be implemented when there are ongoing MRSA transmissions, current infections, previous colonization, and in other special circumstances. The basis of this recommendation was made by a “general consensus and was not necessarily evidenced-based” (Siegel, 2006, p. 26). Therefore, there is still an ongoing debate about the optimal strategies for controlling these multi-drug resistant organisms (MDROs). When there is a lack of evidenced-based research, it causes a predicament when deciding which level of precautions should be implemented in the hospital setting.

The general guideline is that standard precautions include: hand hygiene upon entering patient rooms, after coming in contact with any bodily secretions, after removing gloves, when leaving patient rooms; gloving when the likelihood of contacting infectious materials or blood is high; masks and/or goggles for procedures when an increased risk of being splashed with bodily fluids or blood is present; gowning if contamination of clothing is reasonably anticipated (CDC, 2010). While contact precautions include: single-patient rooms when available, otherwise cohorting like patients; gloving upon entering patient rooms; gowning upon entering patient rooms; the use of disposable or patient-dedicated equipment; removal and disposal of all person protective equipment before leaving the patient room (CDC, 2010).

However, large medical centers have begun implementing the use of standard precautions for MRSA infections or colonizations. These transmission-based precaution policies list that contact precautions are not instituted unless the MDRO is deemed epidemiologically significant by the infection control department.

 LOOKING AT THE LITERATURE

   The Center for Disease Control (CDC) recommends that contact precautions be implemented for multidrug resistant organisms (Siegel, 2006). However, large medical centers have recently changed their transmission-based precautions policies on multidrug resistant organisms (infection or colonization) to standard precautions. These precaution policies have an essential role in minimizing the risk for contracting an infection such as MRSA in hospital patients, employees, and visitors. The following literature review examines the inconsistencies related to the continuous use of protective barriers (contact precautions) for MRSA or negating these barriers (standard precautions) as a means to finding the appropriate precaution level for controlling this potentially life-threatening infection.  

Grant, Ramman-Haddad, Dendukuri, and Libman (2006) examined the role of gown use versus a new protocol of non-gown use in preventing the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in a community teaching hospital. Researchers concluded that, “although there was a slightly greater decrease in the number of transmissions in wards where the new protocol was implemented, this number did not significantly differ from the number of transmission in wards where the new protocol was not used” (Grant et al., 2002, p.192). However, it is important to note that a hospital-wide outbreak of Clostridium

difficile diarrhea occurred during the study, possibly enhancing hand-washing compliance, and thereby making it hard to distinguish the true reason for the decrease in MRSA transmissions. 

Webster and Pritchard (2009) conducted a systematic review and meta-analysis that examined the use of gowning compared to non-gowning by attendants and visitors in limiting death, infection, or bacterial colonization in infants admitted to newborn nurseries. Eight studies were utilized in this analysis, but only two were described as being satisfactory. Yet, the researchers concluded that “overall, not wearing a gown was associated with a trend towards reduction in death rate, but these results did not reach statistical significance” (Webster and Pritchard, 2009, p. 5).            Safdar, Marx, Meyer, and Maki (2006) examined the effectiveness of preemptive barrier precautions in containing methicillin-resistantStaphylococcus aureus (MRSA) outbreaks in a burn unit as well as a 27-month follow up. Full-barrier precautions (new clean gown and gloves) were utilized for all patients found to have MRSA (infected or colonized) and were later utilized for all patients on the unit as well. The results of the study suggested a decrease in the outbreak of MRSA on the unit; however they were not statistically significant when compared to pre-full-barrier precautions rates for all patients (Safdar et al., 2006). It is important to note that there was an uncontrolled study design, rendering it impossible to conclude that the implementation of preemptive barrier precautions was the defining measure in stopping the MRSA outbreak.

According to Thompson (2010), an earlier study conducted from the same intensive care unit that resulted in a 75% decrease in the acquisition rate of methicillin-resistant Staphylococcus aureus (MRSA) between 1996 and June 2008. However, this decrease in MRSA occurred at a time when the unit was moving to a new location and new measures were being implemented in the ICU. These measures included deep cleaning, improved ventilation, daily washing of all patients with Stellisept®, standardized care of lines, appropriate scrubs for doctors, and wipeable keyboards. Therefore, the previous study did not conclude the cause of the decreased rates of MRSA. As a result, a second study was conducted in the same ICU that looked at acquisition rates, MRSA contracted at admission or after, and the number of inpatient hospital days. It was confirmed that better infection control within the ICU was the factor for an overall decreased MRSA rate in the first three periods of the study (1996 to 2006). However, the study demonstrated that new infection control measures taken afterward in the ICU (from December 2006 to June 2009) had no benefit. This reduction in the acquisition rate was determined to be from a decrease in the prevalence of MRSA on admission (Thompson, 2010).

Each of the previous studies is inconclusive in defining the most effective level of precautions for preventing the spread of MRSA. All the studies resulted in an absence of statistically significant data, and could not prove the superiority of one method. Therefore, further evidenced-based research is warranted to evaluate the use of contact precautions over standard precaution in the role of preventing the spread of MRSA among hospital patients, employees, and visitors.IMPLICATIONS FOR PRACTICE

It is important to base clinical decisions on evidenced based research findings to protect all parties involved. The decision to don gown and gloves prior to entering an infected or colonized MRSA room appears to be uncertain in some health care settings. Since MRSA organisms are transferred onto the clothes and hands of healthcare workers during routine patient contact, nurses who predominate in bedside care tend to be the culprits of cross contamination. As a result, evidenced-based MRSA transmission precaution policies are important in the field of nursing to control the spread of MDROs.

The discrepancies between standard or contact precautions implemented in some institutions demonstrates that more definitive research should be conducted to determine the most effective infection control measures in preventing the spread of MRSA. The repercussions of the lack of an evidenced-based universal standard could result in an increase of MRSA outbreaks if control measures are not properly executed. The use of contact precautions does not have a statistical significance in controlling MRSA over standard techniques accompanied by adequate hand hygiene. The possibility that contact precautions are more detrimental than beneficial to patients remains unknown.

Contact precautions can have an impact on patient care, though few studies are examining this topic. Studies found that health care providers were not as likely to enter patient rooms that were designated with contact precautions (Siegel, 2006, p.26). In addition patients on contact precautions had increased anxiety, increased depression scores, expressed greater dissatisfaction with their treatment, and had less documented care than non-contact patients (Siegel, 2006). Therefore, it is essential that further research be conducted to examine the effectiveness of evidenced-based control strategy and its effect on patient care.

Education is one of the best prevention techniques available. Better informed health care professionals, patients, and visitors are on MRSA prevention is essential. Proper cleansing and disposing of patient equipment should be completed on a regular basis, regardless of MRSA culture results. However, proper hand hygiene techniques are considered one of the best control methods in breaking the chain of infection. It is crucial to encourage hand hygiene before entering patient rooms, after contact with bodily fluids, after contact with equipment, after removing gloves, and when leaving patient rooms. These simple actions prevent patient cross contamination and offers protection to other health care providers and visitors alike.