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Chautauqua '92: Challenges, Changes, and Choices
AORN JOURNAL
NOVEMBER 1992, VOL 56, NO 5
Colorado Nurses’ Association’s Annual Educational Seminar
C
hautauqua ’92: Challenges, Changes, and Choices
Aug 7 to 11,1992
T
he 17th annual Colorado Nurses’ Association (CNA) continuing education program, known as Chautauqua, was held Aug 7 to 11, 1992, in Vail, Colo. The theme of this year’s program was “Challenges, Changes, and Choices.” The program drew more than 450 participants from across the United States and as far away as Japan, Germany, England, and Turkey. The goals of this year’s Chautauqua were to discuss directions and trends in current nursing practice, identify strategies and interventions that can be incorporated into existing nursing practice settings, and examine and review personal and professional goals. Nearly 50 seminars and lectures covering a wide variety of clinical, administrative, and educational topics were presented. The following is a short synopsis of several presentations.
Influencing Strategies
E
lizabeth A. Buck, RN, PhD, spoke on “Influencing Strategies-How to Get What You Want Almost Painlessly.” Dr Buck, who is an assistant professor at Southern Illinois University at Edwards-
ville School of Nursing, stressed that a positive rather than a negative approach to influencing often works the best. “As nurses, we don’t believe that we have to influence anyone,” said Dr Buck. “But we often think too narrowly when you consider the power and clout that we have as nurses. Our nursing knowledge and clinical competency are just a few sources of power that we can use to influence others. We can make a positive change for our world if we make sure that society knows that there is power in caring.” Dr Buck used a strategy developed by A. R. Cohen and D. L. Bradford to demonstrate how to influence other people through the method of exchange. “This whole method is based upon the law of reciprocity,” she said. “When you want to get something, think about stopping the negative cycle. Assume the person you are trying to influence is an ally. This can be difficult, but you need to build a trusting relationship. Clarify your goals and priorities by deciding what you want and what’s important to you. Then, don’t get sidetracked.”
Elizabeth A. Buck
“Next, diagnose your ally’s world by figuring out the person’s goals, concerns, and needs,” Dr Buck said. “Go to the person and actually ask them what they want. Then, you can assess your resources relative to what your ally holds valuable. This will enable you to diagnose your relationship with your ally, determine what you are going to exchange, and make the exchanges.”
CodependencyIssues
R
othlyn “Rorry” Zahourek, RN, MS, CS, who is in private mental health practice, presented “Are Nurses Codependent?” Codependency 943
AORN JOURNAL
Rothlyn Zahourek
was first identified in family members of alcoholics, but it is now recognized as common in families where children were raised in a dysfunctional way. According to research, codependents have learned that it is not okay to talk about problems or openly express feelings. They communicate indirectly and find i t unacceptable t o “rock the boat.” The message codependents are taught by the dysfunctional family is that they must be strong, perfect people at all times. They are not allowed to let the system down, and it is not okay for them to play or express their needs. Nurses can have a hard time deciding where being a good nurse stops and being codependent begins, but it is important to know for their own health. Codependents are at risk of becoming physically ill or dying from accidents and suicide. Zahourek presented signs and symptoms of codependence to the group and asked them to talk about how they felt code-
-
pendency applied to nursing. When Zahourek asked, “Do you think Florence Nightingale and Mother Theresa are codependent?” a lively debate began for participants. She presented the results of a study conducted by Sullivan in 1988 comparing nurses identified as dependent o r nondependent. Dependent nurses were found to have experienced a high (ie, 40%) rate of incest or rape, were more likely to have married someone or have a family member who was chemically addicted, and to have parents who had died of substance abuse or suicide, Zahourek related that in a survey done by E. Williams, L. Bissell, and E. Sullivan, at a chemical dependency conference attended by nurses and physicians in 1991, the majority of respondents felt that their lives were seriously affected by codependence and living with a person who was chemically addicted. Zahourek reviewed common theories about codependence and discussed conventional therapy available to people. She also offered a well-rounded reading list for those interested in pursuing the topic.
NOVEMBER 1992, VOL 56,NO 5
Valley Hospital, Fort Collins, Colo, and Eleanor Stockbridge, RN, MS, CRRN, head nurse, life skills rehabilitation, Poudre Valley Hospital, Fort Collins, Colo. According to Dr Kruckenberg Schofer, the Practice Partnership Program, developed as a pilot in spring of 1991, is a care extender program. The partnership pairs an experienced registered nurse who is the senior partner with a practice partner who is usually a new graduate. The partners work together o n the same shift, share an expanded patient load, and develop a synergy between them. “New programs that are risk taking and place nurses in the forefront are incredible undertakings,” said Dr Kruckenberg Schofer. “But, we wanted to develop a unique program that would use our professional staff members to their best advantage, provide patients with the best possible care, and address concerns about cost of care.” Stockbridge explained how
Nursina Practice
T
e concept of nursing practice partnerships was presented by Karna Kruckenberg Schofer, RN, PhD, associate administrator, patient care services, Poudre
Karna Kruckenberg Schofer
NOVEMBER 1992,VOL 56, NO 5
the partners, patients, and hospital benefit from the program. “A practice partnership expands the role and accountability of the RN because the nurse becomes a teacher or mentor,” she said. “While many hospitals are reverting to the task-based use of assistants for routine patient care needs, the partnership program ensures that caregiver decisions match patient need with caregiver skill.” Advantages to the senior partner include role satisfaction; increased self esteem; and development of supervisory skills including the ability to delegate responsibilities, evaluate others, and teach new skills. The practice partner gains a consistent teacher, improved skills development, and job satisfaction. Patients perceive that they are receiving more care with two caregivers and that their needs are being met more quickly, while the potential for improved outcomes increases. Hospitals improve staff utilization, decrease liability, and can use the program as a recruitment and retention benefit.
Ethical Issues
E
thical decision making and institutional ethics committee development were covered in “Twirling the Spindle,” presented by Judi Guy, RN, MSN, CCRN, a clinical specialist with Presbyterian-St Luke’s Healthcare System, Denver. After outlining the components of the ethical decision making process (eg, reviewing situations, gathering information, identifying per-
AORN JOURNAL
sonal and professional values), Guy compared and contrasted requirements, advantages, and disadvantages of living wills and durable powers of attorney. “What’s actually best is a durable power of attorney for health care decisions. This document actually goes farther than just a regular durable power of attorney because it gives the health care team a road map that they can follow should you be critically injured or ill,” said Guy. She also stressed that people should check their state laws to ensure that their living wills and durable powers of attorney are legally enforceable. Regarding ethics committees, Guy said that all hospitals should have policies. “It isn’t always feasible to have a large ethics committee in smaller hospitals, and it really isn’t necessary. Your committee can consist of one or two people who keep current on ethics issues.” She added that all committees should strive to educate the community; formulate, monitor, and revise policies and guidelines; and be available to advise staff members on ethical problems.
Stress Disorder
C
arola Sena, RN, MSN, CNA, nurse manager, Department of Veterans Affairs Medical Center, Albuquerque, and Jane Walsh, RN, MSN, CS, clinical specialist, Post Traumatic Stress Disorder
Judi Guy
Program, Department of Veterans Affairs Medical Center, Albuquerque, presented a session on “Post Traumatic Stress Disorder: Update in a Violent Society.” Walsh began the session by recounting a harrowing experience that she and her teenage son experienced that led to posttraumatic stress disorder (PTSD) for both of them. Her point was that this disorder is not limited to war veterans. Anyone who experiences a traumatic event can suffer from PTSD. Sena discussed the clinical diagnosis and treatment of patients with this disorder. Important aspects that contribute to PTSD are that the event is out of the person’s control, the person has no sense of safety, there is a threat to life, and the person experiences an alteration in the perception of time and space. Many people react to PTSD by drinking, taking drugs, or sleeping; all are a means to avoid or alter the person’s perception of what 945
NOVEMBER 1992, VOL 56, NO 5
AORN JOURNAL
has happened. A diagnosis of PTSD can be made if a patient has experienced a traumatic e v e n t , has h a d at least o n e episode of mentally “re-experiencing” the event (ie, flashbacks), displays at least three avoidance symptoms and two hyperarousal symptoms (also known as “bunker mentality”),
and experiences these symptoms for at least one month. Posttraumatic stress disorder can be acute or chronic and can have a delayed onset of up to six months after a traumatic event has occurred. Both of the speakers used nursing diagn o s e s ( e g , p o s t t r a u m a response, inefficient individual
coping, sleep pattern disturbance) to pinpoint areas where the patient can be helped to overcome PTSD. CELESTEGOLDBAUM EDITOR ASSOCIATE HELENSTARBUCK PASHLEY, RN, BSN, CNOR CLINICAL EDITOR
Current Methods Underdiagnose Herpes
Reasons for High Health Costs
The current strategy for diagnosing genital herpes simplex virus (HSV) infection, which relies on clinical findings and the selective use of viral culture, misses many cases, according to an article in the June 4, 1992, issue of The NeH- England .loui.nal of Medicine. Newly developed type-specific serologic methods can identify women with unrecognized or subclinical infection, the article states. Physical examinations, Pap smears, viral cultures, and HSV type-specific serologic assays were performed on 779 randomly selected women attending a sexually transmitted disease clinic. Of the 372 women who had positive cultures indicative of HSV infection, 216 (ie, 5 8 % ) had antibodies to HSV type 2 with no viral shedding and no history of clinical episodes. They were identified as having HSV type 2 only on the basis of serologic screening. According to the article, only 39% of women with past or current urogenital or anorectal HSV infection were identified by current standard methods of history taking and clinical examination. This lack of recognition of infection among infected people is a factor in the continued spread of HSV type 2 infection in the United States, the article states.
Although more than half of all US hospitals are losing money, regulators attempting to control health care costs focus on controlling hospital expenditures. In the past three years, hospitals have had to reduce cash reserves to meet operating costs, and many hospitals have had to eliminate services such as trauma centers and high-risk obstetric services, according to an article in the June 20, 1992, issue of Hospitals. It is not hospital expenditures that are causing health care costs to increase, however. According to the article, the real causes include societal problems of poverty, lack of education, homelessness, drug abuse, alcoholism, smoking, poor diet, lack of exercise, stress, hurried lifestyles, trauma, violence, abuse, and pollution. Although not normally linked to health care costs, each of these elements has enormous inflationary impact on health care costs. Other factors driving health care costs up are society’s demand for the best health care available and irrational delivery of care. The article cites examples of irrational health care delivery, including spending $3 billion annually on neonatal care while denying thousands of women prenatal care, and spending $lS,OOO for every open heart surgery while ignoring routine treatment for hypertension, high cholesterol, and smoking addiction.
946
NOVEMBER 1992, VOL 56, NO 5
Colorado Nurses’ Association’s Annual Educational Seminar
C
hautauqua ’92: Challenges, Changes, and Choices
Aug 7 to 11,1992
T
he 17th annual Colorado Nurses’ Association (CNA) continuing education program, known as Chautauqua, was held Aug 7 to 11, 1992, in Vail, Colo. The theme of this year’s program was “Challenges, Changes, and Choices.” The program drew more than 450 participants from across the United States and as far away as Japan, Germany, England, and Turkey. The goals of this year’s Chautauqua were to discuss directions and trends in current nursing practice, identify strategies and interventions that can be incorporated into existing nursing practice settings, and examine and review personal and professional goals. Nearly 50 seminars and lectures covering a wide variety of clinical, administrative, and educational topics were presented. The following is a short synopsis of several presentations.
Influencing Strategies
E
lizabeth A. Buck, RN, PhD, spoke on “Influencing Strategies-How to Get What You Want Almost Painlessly.” Dr Buck, who is an assistant professor at Southern Illinois University at Edwards-
ville School of Nursing, stressed that a positive rather than a negative approach to influencing often works the best. “As nurses, we don’t believe that we have to influence anyone,” said Dr Buck. “But we often think too narrowly when you consider the power and clout that we have as nurses. Our nursing knowledge and clinical competency are just a few sources of power that we can use to influence others. We can make a positive change for our world if we make sure that society knows that there is power in caring.” Dr Buck used a strategy developed by A. R. Cohen and D. L. Bradford to demonstrate how to influence other people through the method of exchange. “This whole method is based upon the law of reciprocity,” she said. “When you want to get something, think about stopping the negative cycle. Assume the person you are trying to influence is an ally. This can be difficult, but you need to build a trusting relationship. Clarify your goals and priorities by deciding what you want and what’s important to you. Then, don’t get sidetracked.”
Elizabeth A. Buck
“Next, diagnose your ally’s world by figuring out the person’s goals, concerns, and needs,” Dr Buck said. “Go to the person and actually ask them what they want. Then, you can assess your resources relative to what your ally holds valuable. This will enable you to diagnose your relationship with your ally, determine what you are going to exchange, and make the exchanges.”
CodependencyIssues
R
othlyn “Rorry” Zahourek, RN, MS, CS, who is in private mental health practice, presented “Are Nurses Codependent?” Codependency 943
AORN JOURNAL
Rothlyn Zahourek
was first identified in family members of alcoholics, but it is now recognized as common in families where children were raised in a dysfunctional way. According to research, codependents have learned that it is not okay to talk about problems or openly express feelings. They communicate indirectly and find i t unacceptable t o “rock the boat.” The message codependents are taught by the dysfunctional family is that they must be strong, perfect people at all times. They are not allowed to let the system down, and it is not okay for them to play or express their needs. Nurses can have a hard time deciding where being a good nurse stops and being codependent begins, but it is important to know for their own health. Codependents are at risk of becoming physically ill or dying from accidents and suicide. Zahourek presented signs and symptoms of codependence to the group and asked them to talk about how they felt code-
-
pendency applied to nursing. When Zahourek asked, “Do you think Florence Nightingale and Mother Theresa are codependent?” a lively debate began for participants. She presented the results of a study conducted by Sullivan in 1988 comparing nurses identified as dependent o r nondependent. Dependent nurses were found to have experienced a high (ie, 40%) rate of incest or rape, were more likely to have married someone or have a family member who was chemically addicted, and to have parents who had died of substance abuse or suicide, Zahourek related that in a survey done by E. Williams, L. Bissell, and E. Sullivan, at a chemical dependency conference attended by nurses and physicians in 1991, the majority of respondents felt that their lives were seriously affected by codependence and living with a person who was chemically addicted. Zahourek reviewed common theories about codependence and discussed conventional therapy available to people. She also offered a well-rounded reading list for those interested in pursuing the topic.
NOVEMBER 1992, VOL 56,NO 5
Valley Hospital, Fort Collins, Colo, and Eleanor Stockbridge, RN, MS, CRRN, head nurse, life skills rehabilitation, Poudre Valley Hospital, Fort Collins, Colo. According to Dr Kruckenberg Schofer, the Practice Partnership Program, developed as a pilot in spring of 1991, is a care extender program. The partnership pairs an experienced registered nurse who is the senior partner with a practice partner who is usually a new graduate. The partners work together o n the same shift, share an expanded patient load, and develop a synergy between them. “New programs that are risk taking and place nurses in the forefront are incredible undertakings,” said Dr Kruckenberg Schofer. “But, we wanted to develop a unique program that would use our professional staff members to their best advantage, provide patients with the best possible care, and address concerns about cost of care.” Stockbridge explained how
Nursina Practice
T
e concept of nursing practice partnerships was presented by Karna Kruckenberg Schofer, RN, PhD, associate administrator, patient care services, Poudre
Karna Kruckenberg Schofer
NOVEMBER 1992,VOL 56, NO 5
the partners, patients, and hospital benefit from the program. “A practice partnership expands the role and accountability of the RN because the nurse becomes a teacher or mentor,” she said. “While many hospitals are reverting to the task-based use of assistants for routine patient care needs, the partnership program ensures that caregiver decisions match patient need with caregiver skill.” Advantages to the senior partner include role satisfaction; increased self esteem; and development of supervisory skills including the ability to delegate responsibilities, evaluate others, and teach new skills. The practice partner gains a consistent teacher, improved skills development, and job satisfaction. Patients perceive that they are receiving more care with two caregivers and that their needs are being met more quickly, while the potential for improved outcomes increases. Hospitals improve staff utilization, decrease liability, and can use the program as a recruitment and retention benefit.
Ethical Issues
E
thical decision making and institutional ethics committee development were covered in “Twirling the Spindle,” presented by Judi Guy, RN, MSN, CCRN, a clinical specialist with Presbyterian-St Luke’s Healthcare System, Denver. After outlining the components of the ethical decision making process (eg, reviewing situations, gathering information, identifying per-
AORN JOURNAL
sonal and professional values), Guy compared and contrasted requirements, advantages, and disadvantages of living wills and durable powers of attorney. “What’s actually best is a durable power of attorney for health care decisions. This document actually goes farther than just a regular durable power of attorney because it gives the health care team a road map that they can follow should you be critically injured or ill,” said Guy. She also stressed that people should check their state laws to ensure that their living wills and durable powers of attorney are legally enforceable. Regarding ethics committees, Guy said that all hospitals should have policies. “It isn’t always feasible to have a large ethics committee in smaller hospitals, and it really isn’t necessary. Your committee can consist of one or two people who keep current on ethics issues.” She added that all committees should strive to educate the community; formulate, monitor, and revise policies and guidelines; and be available to advise staff members on ethical problems.
Stress Disorder
C
arola Sena, RN, MSN, CNA, nurse manager, Department of Veterans Affairs Medical Center, Albuquerque, and Jane Walsh, RN, MSN, CS, clinical specialist, Post Traumatic Stress Disorder
Judi Guy
Program, Department of Veterans Affairs Medical Center, Albuquerque, presented a session on “Post Traumatic Stress Disorder: Update in a Violent Society.” Walsh began the session by recounting a harrowing experience that she and her teenage son experienced that led to posttraumatic stress disorder (PTSD) for both of them. Her point was that this disorder is not limited to war veterans. Anyone who experiences a traumatic event can suffer from PTSD. Sena discussed the clinical diagnosis and treatment of patients with this disorder. Important aspects that contribute to PTSD are that the event is out of the person’s control, the person has no sense of safety, there is a threat to life, and the person experiences an alteration in the perception of time and space. Many people react to PTSD by drinking, taking drugs, or sleeping; all are a means to avoid or alter the person’s perception of what 945
NOVEMBER 1992, VOL 56, NO 5
AORN JOURNAL
has happened. A diagnosis of PTSD can be made if a patient has experienced a traumatic e v e n t , has h a d at least o n e episode of mentally “re-experiencing” the event (ie, flashbacks), displays at least three avoidance symptoms and two hyperarousal symptoms (also known as “bunker mentality”),
and experiences these symptoms for at least one month. Posttraumatic stress disorder can be acute or chronic and can have a delayed onset of up to six months after a traumatic event has occurred. Both of the speakers used nursing diagn o s e s ( e g , p o s t t r a u m a response, inefficient individual
coping, sleep pattern disturbance) to pinpoint areas where the patient can be helped to overcome PTSD. CELESTEGOLDBAUM EDITOR ASSOCIATE HELENSTARBUCK PASHLEY, RN, BSN, CNOR CLINICAL EDITOR
Current Methods Underdiagnose Herpes
Reasons for High Health Costs
The current strategy for diagnosing genital herpes simplex virus (HSV) infection, which relies on clinical findings and the selective use of viral culture, misses many cases, according to an article in the June 4, 1992, issue of The NeH- England .loui.nal of Medicine. Newly developed type-specific serologic methods can identify women with unrecognized or subclinical infection, the article states. Physical examinations, Pap smears, viral cultures, and HSV type-specific serologic assays were performed on 779 randomly selected women attending a sexually transmitted disease clinic. Of the 372 women who had positive cultures indicative of HSV infection, 216 (ie, 5 8 % ) had antibodies to HSV type 2 with no viral shedding and no history of clinical episodes. They were identified as having HSV type 2 only on the basis of serologic screening. According to the article, only 39% of women with past or current urogenital or anorectal HSV infection were identified by current standard methods of history taking and clinical examination. This lack of recognition of infection among infected people is a factor in the continued spread of HSV type 2 infection in the United States, the article states.
Although more than half of all US hospitals are losing money, regulators attempting to control health care costs focus on controlling hospital expenditures. In the past three years, hospitals have had to reduce cash reserves to meet operating costs, and many hospitals have had to eliminate services such as trauma centers and high-risk obstetric services, according to an article in the June 20, 1992, issue of Hospitals. It is not hospital expenditures that are causing health care costs to increase, however. According to the article, the real causes include societal problems of poverty, lack of education, homelessness, drug abuse, alcoholism, smoking, poor diet, lack of exercise, stress, hurried lifestyles, trauma, violence, abuse, and pollution. Although not normally linked to health care costs, each of these elements has enormous inflationary impact on health care costs. Other factors driving health care costs up are society’s demand for the best health care available and irrational delivery of care. The article cites examples of irrational health care delivery, including spending $3 billion annually on neonatal care while denying thousands of women prenatal care, and spending $lS,OOO for every open heart surgery while ignoring routine treatment for hypertension, high cholesterol, and smoking addiction.
946