Dedicated to the health and safety of healthcare workers

D E P A R T M E N T S

FALL 2007 VOL. XXVII, NO. 4

27Critical Competency: Determining and Communicating the

Number of Nurses You Must Hire

Joan Ellis Beglinger, MSN, MBA, RN, FACHE, FAAN

29Addressing Multigenerational Conflict: Mutual Respect and

Carefronting as Strategy

Betty R. Kupperschmidt, EdD, RN, CNAA

35The Health Benefits of Fiber

W. Steven Pray, PhD, DPh

38Relationship of Antimicrobial Control Policies and Hospital and

Infection Control Characteristics to Antimicrobial Resistance

Rates

Elaine L. Larson, RN, PhD; Dave Quiros, MS; Tara Giblin, RN, MPH; Susan Lin, DrPH

3 President’s Message

4 Vice President’s Update

7 Editor’s Column

8 Association Community Liason Report

10 Industrial Hygiene in Healthcare

12 Talking Points in Heathcare Ergonomics

15 Ready to Research

18 Spotlight on an AOHP Star

20, 22,

26 Collegue Connection

F E A T U R E S

High Tea High Tea at 2007 AOHP conference at 2007 AOHP conference

opening receptionopening reception

There was much good-natured competition to design the “to die for” hat!

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Fall 2007

President’s MessageBy Denise Knoblauch, RN, BSN, COHN-S/CM

Denise KnoblauchAOHP ExecutivePresident

It is hard to believe this is my next to last column. Our Journal editor will only have to send a gentle reminder to me one more time, for which I am sure she is very thank-ful. The past four years, serv-ing as AOHP Executive Presi-dent, have just fl own by. And AOHP not only survived, but fl ourished.

As I prepared my thoughts to write this column, the word “transition” came to mind. I will be paraphrasing Walter Cronkite’s farewell broad-cast message from March 6, 1981. This is my next to last president’s column for AOHP Journal, which I have been writing for the past four years. It is a moment for which I have planned, but which comes with sadness.

This is not a departure but a transition, a passing of the baton. A great occupational health professional, Mary-Ann Gruden, preceded me in this role, and another, Sandy

I encourage all of you to “dream big” and strive to make those dreams come true. Let us all dream and work toward a membership that continues to grow. Help AOHP become the association of choice for occupational health profession-als in healthcare for all levels of professionals, including physicians and advanced practice nurses.

Prickitt, will follow. Actually, the person fi lling this role is but the most conspicuous member of a superb team of occupational health profes-sionals who serve as a great management team, and none of that will change.

Furthermore, I am not going very far away! I will continue as President Emeritus and plan to be the 2009 confer-ence chair in Portland, Ore-gon. Old occupational health professional board members don’t fade away; they just fi nd other roles, such as chap-ter offi cers or participating on national committees.I will miss my contact with members and chapters. You, the membership, are the ones who feel the passion and show the pride in occu-

pational health in healthcare every day. You are all jewels to be treasured and remem-bered.

One accomplishment I am very pleased that occurred during my tenure was the ap-proval and acceptance of two new chapters. Kudos and many thanks to Lynne Kar-nitz, AOHP Region 2 Director, for accomplishing this amaz-ing feat.

I encourage all of you to “dream big” and strive to make those dreams come true. Let us all dream and work toward a member-ship that continues to grow. Help AOHP become the as-sociation of choice for occu-pational health professionals in healthcare for all levels of professionals, including phy-sicians and advanced practice nurses.

The Executive Board depends on you, the members, for insights, wisdom and guid-ance.

Thank you for your belief in the future of this great as-sociation. And thank you for a great four years. We have and we will continue to ac-complish much together.

Denise KnoblauchExecutive President

In Search of…Best Practices in Occupational Health

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Vice President’s UpdateBy Sandra Domeracki Prickitt, RN, FNP, COHN-S

Sandra Domeracki PrickittAOHP Vice President

During the second quarter of 2007, the Centers for Dis-ease Control and Prevention (CDC) released several docu-ments that relate to the prac-tice of occupational health in the healthcare setting. These documents are: Prevention and Control of Infl uenza, Prevention of Varicella, and Guideline for Isolation Pre-cautions: Preventing Trans-mission of Infectious Agents in Healthcare Settings 2007. These are all lengthy docu-ments, so I thought it would be helpful for you to have a summary of what has changed since previous doc-uments were published on these topics.

Prevention and Control of Infl uenzaThe CDC’s Advisory Commit-tee on Immunization Prac-tices (ACIP) provides annual recommendations for the prevention and control of in-fl uenza. It released this year’s recommendations in June 2007. Below are some of the recommendations that were reiterated and/or changed:

The groups of persons for whom vaccination is recommended and an-tiviral medications rec-ommended for chemo-prophylaxis or treatment have not changed.Vaccination coverage for healthcare personnel re-mains at about only 42 percent.ACIP recommends that healthcare administra-tors consider the level

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of vaccination coverage among healthcare per-sonnel to be a measure of a patient safety quality program and to imple-ment policies to encour-age healthcare person-nel vaccination. This is to include obtaining signed declinations from per-sonnel who decline the vaccine for reasons oth-er than medical contrain-dications.Infl uenza vaccination rates among healthcare personnel should be measured regularly, be reported and be depart-ment specifi c, with cov-erage rates provided to staff and administration.The 2007-2008 vac-cine includes: A/Solo-mon Islands/3/2006 (H1N1) [new for this season,],A/Solomon Is-lands/3/2006 (H1N1)-like [new for this season,] A/Wisconsin/67/2005 (H3N2)-like, and B/Ma-laysia/2506/2004-like an-tigens.Infl uenza B viruses un-dergo antigenic drift less frequently than Infl uenza A viruses.The typical incubation

period for infl uenza is one to four days (average two days.) Adults can be infectious from the day before symptoms begin through approximately fi ve days after illness onset. Young children can shed virus several days before onset of

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symptoms and can be infectious >10 days af-ter onset of symptoms. Severely immunocom-promised persons can shed virus for weeks or months.Lower postvaccination anti-infl uenza antibody concentrations have been reported among certain older persons compared with younger adults. Immunity might also be of shorter dura-tion and less likely to extend to a second sea-son in this population as well.No studies conducted using infl uenza vaccines other than the 1976 swine infl uenza vaccine have demonstrated a substantial increase in Guillain-Barre Syndrome.In January 2007, a new formulation of Live, At-tenuated Infl uenza Vac-cine (LAIV) [sold under the brand name FluMist] was licensed to replace the older formulation this season. The main differ-ences with this updated vaccine are:1. It is supplied in pre-

fi lled, single-use spray-ers containing 0.2 mL of vaccine.

2. It can be shipped and stored at 25-46 de-grees F until the expi-ration date is reached.

Vaccination of healthcare personnel is associated with reduced work ab-senteeism and with few-

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CDC’s Recent Infl uenza, Varicella and Isolation Guidelines

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er deaths among nursing home patients and elder-ly hospitalized patients.All healthcare personnel should be vaccinated, in-cluding physicians, medi-cal emergency response workers and students in healthcare professions.

Prevention of VaricellaACIP, in this document, has updated the recommenda-tions that were made prior in its 1996 and 1999 docu-ments. ACIP now recom-mends: 1) a second catch-up varicella vaccination for adolescents and adults who previously received 1 dose, and 2) routine vaccination of all healthy persons aged >13 years without evidence of immunity. Since the United States implemented a uni-versal varicella vaccination program for children in 1995, there have been substantial declines in morbidity and mortality related to varicella. ACIP recommends the fol-lowing which affects our practice:

As disease incidence de-creases and the propor-tion of vaccinated per-sons with varicella having mild cases increases, it will be less readily rec-ognized clinically. There-fore, evidence of immu-nity should be either a diagnosis of varicella by a healthcare provider, proof of two vaccina-tions or positive sero-logic titer.Postvaccination serolog-ic testing is not recom-mended because avail-able commercial assays lack the sensitivity in de-tecting vaccine-induced immunity and might give false negative results.Vaccines must be stored frozen at an average tem-

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perature of 5 degrees F or colder. Freezers that reliably maintain an aver-age temperature of <5 degrees F and that have a separate sealed freez-er door are acceptable for storing the vaccine. Stand-alone freezers or the freezer compartment of a refrigerator-freezer combination are also ac-ceptable, provided that the freezer compart-ment has its own sepa-rate, sealed and insu-lated exterior door. Units with an internal freezer door are not acceptable. Temperatures should be documented at the be-ginning and end of each day. Providers should document the required temperature in a newly purchased unit for a mini-mum of one week before using it to store vaccine, and routinely thereafter. When varicella vaccine is stored in the freezer compartment of a com-bined refrigerator-freez-er, temperatures in both compartments should be monitored carefully.When an immunization session is being held offsite, the vials of vac-cine should be packed in either a vaccine shipping container or in an insu-lated cooler with dry ice (a minimum of 6 lbs. per box) to preserve poten-cy. Diluent should not be transported on dry ice.For pregnant women, if prenatal assessment indicates the need for the varicella vaccine, the recommendations for vaccination are as fol-lows: upon completion of the pregnancy, the woman should receive the fi rst dose of vaccine

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before discharge from the healthcare facility. The second dose should be given four to eight weeks later. Women should be counseled to avoid conception for one month after each dose of varicella vaccine. Women who have re-ceived the vaccine post-partum may continue to breastfeed. The majority of live vaccines are not associated with virus se-cretion in breast milk.Persons with impaired humoral immunity may be vaccinated.Healthcare personnel who have received two doses of vaccine and who are exposed to varicella should be moni-tored daily during days 10-21 after exposure through the employee health program to deter-mine clinical status.

Guideline for Isolation Precautions: Preventing Transmission of Infec-tious Agents in Health-care Settings 2007This guideline updates and expands those that were written in 1996. This updated guideline responds to chang-es in healthcare delivery and addresses new concerns about transmission of infec-tious agents to patients and healthcare workers. The ob-jective is to improve the safe-ty of the healthcare system and reduce hospital acquired infections. The following fac-tors led to the update of the guideline:

The transition of health-care delivery from acute hospitals to other health-care settings (more out-patient based.)The emergence of new pathogens.

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The success with Stan-dard Precautions and affi rmation of this ap-proach to add Respira-tory Hygiene/Cough Eti-quette and safe infection practices.Accumulated evidence that environmental con-trols decrease the risk of life-threatening fungal infections in severely im-munocompromised pa-tients.Evidence that organi-zational characteristics infl uence healthcare personnel adherence to recommended infection control practices.Continued increase in the incidence of hospital acquired infections by multidrug-resistant or-ganisms.

The objectives of the guide-line are to:

Provide infection control recommendations for all areas of the healthcare delivery system.Reaffi rm that Standard Precautions are the foun-dation for preventing the spread of infection.Provide evidence-based recommendations.

Changes or clarifi cations in terminology:

Nosocomial infection re-fers only to infections ac-quired in the hospital.Healthcare-associated infection (HAI) refers to infections associated with healthcare delivery in any setting.Respiratory Hygiene/Cough Etiquette applies broadly to all persons who enter a healthcare setting, whereas Stan-dard Precautions ap-plies to the practices of healthcare personnel during patient care.

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Airborne Precautions has been supplemented with the term Airborne Infection Isolation Room (AIIR) for consistency.Protective Environ-ment has been added to prevent HAIs. These measures consist of en-gineering and design in-terventions that decrease the risk of exposure to environmental fungi for severely immunocom-promised allogeneic he-matiopoietic stem cell transplant patients.

Changes and additions that affect occupational health in the healthcare setting:

Agents of bioterrorism. A different set of issues arise when dealing with these agents versus other communicable dis-eases. Infection control measures need to ad-dress: identifying those that have been exposed, preventing transmission, providing treatment, pro-tecting the environment, providing enough per-sonal protective equip-ment (PPE,) and identify-ing appropriate staff to care for potentially infec-tious patients.Pre-event administration of smallpox (vaccinia) vaccine to healthcare personnel is discussed in some detail.A key administrative measure is the provi-sion of fi scal and human resources for maintain-ing infection control and occupational health pro-grams that are respon-sive to emerging needs. Many administrative factors can affect the transmission of infec-tious agents in health-care settings: institu-tional culture, individual

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worker behavior and the work environment. Each of these areas is suitable for performance improvement monitoring and incorporation into the organization’s patient safety goals. Education programs for healthcare personnel have been associated with sustained improve-ment in adherence to best practices and a re-lated decrease in device-associated HAIs.Gloves need to be used: with anticipation of di-rect contact with blood or body fl uids, mucous membranes, nonintact skin and other poten-tially infectious material; when having direct con-tact with patients who are colonized or infected with pathogens transmit-ted by the contact rouge (VRE, MRSA< RSV, etc.;) or when handling or touching visibly, poten-tially contaminated pa-tient care equipment and environmental surfaces. Vinyl gloves have higher failure rates than latex or nitrile gloves. For this reason, either latex or ni-trile gloves are preferred for clinical procedures that require manual dex-terity and/or will involve more than brief patient contact.Respiratory Protection. The OSHA program is referred to in this docu-ment. The document also states that the op-timal frequency of fi t testing has not been determined. NIOSH is currently in the process of doing a study in this area, which will take sev-eral years. The data col-

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lection portion is due to end in 2010.Prevention of needlestick and other sharps-related injuries. The document states that the preven-tion of sharps injuries is an essential part of Stan-dard Precautions.Prevention of mucous membrane contact. This is now an element for Standard Precautions and is subject to OSHA bloodborne pathogen regulations. Precautions during aero-sol-generating proce-dures. The use of par-ticulate respirators is recommended during such procedures where M. tuberculosis, SARS, or avian or pandemic in-fl uenza viruses could be present.Ambulatory settings are encouraged to imple-ment source containment measures to prevent transmission of respira-tory infections (use of surgical masks or cover mouth with coughing.) Patients who are poten-tially infectious should be placed in an examination room immediately to lim-it the number of people who are exposed. Limit the distance between symptomatic and non-symptomatic patients by greater than three feet.New elements of stan-dard precautions. Respi-ratory Hygiene/Cough Etiquette, safe injection practices, and use of masks for insertion of catheters or injection of material into spinal or epidural spaces via lum-bar puncture.PPE, unresolved issues. Use of PPE by health-care workers who are

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presumed to be immune to rubeola, varicella and who work with patients with such diseases. Type of PPE to be worn by susceptible health-care personnel who must have contact with patients with known or suspected measles, varicella or disseminated herpes zoster.Exposure management is discussed regarding use of immunizations or immune globulin to sus-ceptible persons as soon as possible.The document contains appendices that dem-onstrate in text and pic-tures how to don and remove PPE.Droplets can travel up to six feet. Therefore, it is advisable to don a mask when within six to 10 feet of a patient.Some organisms such as Staphylococcus aure-us and noroviruses may become aerosolized and spread over short dis-tances.

Resourceshttp://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm.

References

CDC Isolation Guideline Sparks New Debate on Respiratory Protection. Hos-pital Employee Health, Vol. 26, No. 9, pp 97-100.

Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. June, 2007. pp. 1-219. www.cdc.ogv/ncidod/dhqp/pdf/guidelines/Isola-tion2007.pdf.

Prevention and Control of Infl uenza. CDC, MMWR, 56: 1-54, June 29, 2007.

Prevention of Varicella. CDC, MMWR< 56: 1-40, June 22, 2007.

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Fall 2007

Editor’s ColumnBy Kim Stanchfi eld, RN, COHN-S

Kim Stanchfi eldAOHP Journal Editor

An employee comes to your offi ce proudly pushing forward a “note” from a physician that excuses him or her from a certain task, duty, behavior or work obligation. As Employee Health professionals, we see this all the time.

I continue (20-plus years now) to be amused by the things employees can get physicians to write. And I still shake my head at the large majority of employees who are certain that, just because a physician wrote something, an employ-er will grant that “something.” I continue to see employees every day who fi rmly believe the employer will automatical-ly accept any request, order or restriction that a doctor has written, no matter how odd the request is.

Some of my favorite physician notes include one related to workers’ comp and another regarding a regular medical leave. The work comp note evolved from several weeks of modifi ed duty for a house-keeping employee who did modifi ed tasks in our printing department, making copies while recovering from knee surgery. Her regular house-keeping job required that she work every other weekend, and clean, mop, make beds, empty trash, etc. In the print-ing room on modifi ed duty, her new schedule was straight daylight with weekends off, sitting while copying. She was also permitted to smoke (this was years ago before new smoking policies.) When she had recovered from her knee surgery, she proudly provided me a note by her orthopedic

surgeon that stated “no fur-ther physical restrictions, but must stay working in printing room.” You can just imagine how her smile faded as I ex-plained to her that physicians advise employers on medical limitations and restrictions, but cannot tell us where to employ people.

The other note – and my all time favorite – regarded an employee in our purchasing department. She had been on a three-week medical leave for some mental health issues. Upon her return to work, she provided a note, written by her treating psy-chiatrist, advising “employee may return to work, but not to work with Jane Doe or John Q (synonyms for actual pur-chasing co-workers,) as they cause her increased stress.” I did not make this up.

Frequently, I see employees provide physician notes to push a personal agenda or acquire something they de-sire. When that note results in undesired employment ac-tion (including possible loss of employment,) I often see a new note from the same phy-sician canceling the fi rst note. A miracle recovery on the em-ployee’s part? Not hardly.

So, as Employee Health pro-fessionals, how do we effec-tively deal with this challeng-ing issue? I offer the following recommendations, based on years of “working through it:”

Set expectations with em-ployees up front. Put in writing to Workers’ Comp injured employees that Modifi ed Duty assignments

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are temporary, and the em-ployees are expected to re-turn to their regular jobs.For medical leaves not work related, communicate in writing the return to work expectations and restriction limitations if appropriate.Have in place clearly de-fi ned physical demands and essential functions of jobs.Develop a system where all restrictions/requests are evaluated and managed through Employee Health. If you leave it to the various department supervisors, you will have to deal with inconsistencies.Challenge physicians! Request in writing docu-mented medical reasons for changes.Obtain second opinions and Fitness for Duty Evalu-ations. We are fortunate to have a separate Occu-pational Health Clinic with two board certifi ed Occu-pational Health Physicians.Communicate honestly and openly with the em-ployees. I have found that discussing our process and expectations with em-ployees up front prevents many future requests. Do your homework! If you are not familiar with a job, spend a few hours per-forming that job. Stand your ground!! When you have everything else in place and have done your homework, remain fi rm and consistent.

Hopefully, the next time you get one of those odd physician notes from an employee, you’ll have a few more tools that can assist you to “fi x” the issue.

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“My Doctor’s Note Says It. -- So, You WILL Do It.”

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of the Association of Occupational Health Professionals in Healthcare

Association Community Liaison ReportBy MaryAnn Gruden, CRNP, MSN, NP-C, COHN/S-CM

MaryAnn GrudenAssociation CommunityLiaison

AOHP Visits NIOSH Facilities Near PittsburghDuring the latter part of Au-gust, I had the privilege of vis-iting two National Institute of Occupational and Safety and Health (NIOSH) facilities near Pittsburgh, PA. These vis-its were arranged as part of the Memorandum of Under-standing (MOU) that AOHP signed with NIOSH in 2006. Dr. DeLon Hull, PhD, Direc-tor, Offi ce of Research and Technology Transfer, served as my contact for the visit, and I thank him for taking the time to arrange the visits and meetings with NIOSH staff.

The fi rst visit was to the National Personal Protec-tive Technology Laboratory (NPPTL) in Bruceton, PA. This lab was created in 2001 when Congress underscored the need for improved personal protective equipment (PPE) and encouraged research for personal protective technolo-gies (PPT.)

NPPTL’s mission is to pre-vent work-related injury, ill-ness and death by advancing the state of knowledge and application of PPT. Its vision is to be the leading provider of quality, relevant and timely PPT research, training and evaluation. NPPTL enlists ex-pertise from many scientifi c disciplines to advance fed-eral research on respirators and other PPT for workers. NPPTL’s efforts are essential for applying state-of-the-art science to meet the increas-ingly complex occupational

safety and health challenges of the 21st Century. NPPTL incorporates NIOSH’s long-standing program for testing and approving respirators for use in traditional work set-tings. It also builds on that program to test and approve respirators for use by fi rst re-sponders against chemical, biological, radiological and nuclear agents.

Dr. Raymond Roberge, MD, serves as the Research Med-ical Offi cer for the NPPTL. He shared information related to ongoing and completed re-search projects. In addition, we discussed the concern of the AOHP membership related to the annual fi t test-ing requirement for TB respi-rators. One area of research being addressed is called “anthropometrics.” Anthro-pometrics relates to facial contours and the adequate fi t of respirators. Studies are being done to better predict the fi t of a respirator and vali-dating the annual fi t testing requirement. Although it will take several years for the re-search to be completed, it is an exciting area of research that relates to our practice. I was able to tour several of the research labs, including PPE test chambers.

While at the NPPTL site, I also hade the opportunity to attend several presentations by NIOSH researches at a Research to Practice (r2p) forum. The goal of r2p is to reduce illness and injury by increasing workplace use of effective NIOSH and NIOSH-

funded research fi ndings. To achieve this, NIOSH is con-tinuing to work with partners to focus research on ways to develop effective products, translate research fi ndings into practice, target dissemi-nation efforts, and evaluate and demonstrate the effec-tiveness of these efforts in improving worker health and safety. The presenters shared with internal colleagues how their research fi ndings were put into practice. For more in-formation on the NPPTL, visit these Web sites: http://cdc.gov/niosh/npptl and http://www. fda .gov /cd rh /ppe /masksrespirators.html.

On the second day, I trav-eled to Morgantown, WV, ap-proximately an hour south of Pittsburgh. The NIOSH facil-ity in Morgantown conducts research on the prevention of work-related injuries and respiratory diseases, as well as advanced laboratory re-search on the health effects of work-related exposures.

Meetings with four NIOSH staff members were very interesting. Dr. Nancy A. Stout, EdD, is the Director, Division of Safety Research. We discussed areas of com-mon concern and the role of the division. There are three branches of research within this division. They in-clude Surveillance and Field Investigations, Analysis and Evaluations, and Protective Technology. This division is of particular interest to AOHP, as it is where NIOSH research for safe patient

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handling is based. Captain James W. Collins, PhD, As-sociate Director for Science for the division, is the leading investigator in safe patient handling. In related efforts for safe patient handling re-search, he worked with Dr. Audrey Nelson to develop the curriculum for safe patient handling in nursing schools. Recently, he also completed research related to slip/trip/fall injuries in healthcare.

Dr. Albert E. Munson, PhD, Director, Health Effects Lab-oratory Division, leads six branches that include Allergy and Immunology, Toxicology and Molecular Biology, Physi-ology and Pathology, Expo-sure Assessment, Engineer-ing and Control Technology, and Biostatistics and Epide-miology. This division deals with a wide variety of issues including, but not limited to, latex, mold, biomarkers of disease, capturing air par-ticles for sampling, methods to measure muscle move-ment, and the physiological and psychological effects of high dose stress.

I also met with NIOSH staff member Teri Palermo, the AOHP contact for NORA2. In 1996, the National Occu-pational Research Agenda (NORA) was unveiled as a partnership program to stim-ulate innovative research and improve workplace practices across the nation. Diverse parties collaborated to iden-tify the most critical issues in workplace safety and health. Stakeholders work together to develop goals and objec-tives for addressing these needs. NORA2 is the sec-ond decade of this research effort. We discussed ways that AOHP and the NORA2 Healthcare and Social As-

sistance Council could work together. There are approxi-mately 20 AOHP members who have indicated willing-ness to help review docu-ments from this council as its work evolves. Current topics being addressed by the council include work/life issues and workplace vio-lence. For more information on r2p, visit http://www.cdc.gov/niosh/r2p/.

This was a great two-day experience to meet nation-al leaders in occupational safety and health research and to discuss areas of com-mon concern. The visit will serve as a springboard for a continuing partnership with NIOSH and support the MOU. My appreciation and thanks goes to all the NIOSH staff who took the time to meet with me and share their expertise!

American Heart Association Start! Program and AOHP PartnerAs part of the OSHA Alliance, AOHP has begun partnering with the American Heart As-sociation (AHA) to dissemi-nate information about the AHA “Start!” Program. The goal of the partnership is to build awareness among the AOHP membership of the program’s existence. The goal of the program is to cre-ate a workplace culture of physical activity and health to live longer, heart-healthy lives through walking. The program provides an excel-lent means for a facility to ei-ther start a wellness program or for a facility with a well-ness program to add another component to its wellness efforts.

There are criteria that must be met to become a “Start!” worksite. Materials are fur-nished by the AHA. To in-crease the awareness of this program, AOHP chapters can contact their local AHA and invite a speaker to present “Start!” Program information at a chapter meeting. Or,, as the occupational health pro-fessional, you could contact the local AHA offi ce to obtain more information and/or set up an organizational meet-ing to launch the program. For more information on the “Start!” Program, visit www.americanheart.org/presnter.jhtml?identifi es=3040832.

Hospital eTool Revision ContinuesWork has continued through-out the summer of 2007 on the revision of the OSHA Hospital eTool. The draft of the new Sonography module has been reviewed, and rec-ommendations for changes have been made. Changes for the Bloodborne Pathogen and Ergonomics modules have been made and are be-

ing reviewed by the teams. The goal will be to have the revised eTool completed by the end of 2007.

OSHA/EPA Occupational Chemical Database LaunchedRecently, a new chemi-cal database was launched by the Occupational Safety and Health Administration (OSHA) and the Environmen-tal Protection Agency (EPA.) OSHA and EPA jointly devel-oped and will maintain this database as a convenient ref-erence for the occupational safety and health community. The database provides quick and easy access to informa-tion on more than 800 chemi-cals commonly found in the workplace. This database compiles information from several government agencies and organizations. A num-ber of reports are available from the database and will serve as a useful reference for chemical information. To view this database, visit http://www.osha.gov/web/dep/chemicaldata/#target.

AOHP 2007 Election Results:President:

Sandra Domeracki Prickitt

Secretary: JoAnn Shea

Executive Vice President: Diane Dickerson

(appointed to fi ll one-year vacancy)

Region 2 Director: Lynne Karnitz (re-elected)

Region 4 Director: Carol Cohan (re-elected)

Congratulations to all!

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Industrial Hygiene in Healthcare

Hazards in Histopathology

By George Byrns, MPH, PhD, CIH and Lee Shands, MPH, CIH

In past issues, we discussed specifi c types of hazards and their control. In this issue, we will focus on a specifi c type of laboratory service – histopathology. The purpose of histopathology is to receive, examine, section and stain tissue for eventual microscopic examination by a medical pathologist. This department serves a critical function in disease di-agnosis. The work fl ow starts with an attending health care provider collect-ing specimens during clinical or surgical procedures from a patient who has dis-eased tissue. The provider then submits these tissues to the hospital laboratory for pathologic evaluation.

This is a growing fi eld with high job de-mand. Histopathologists work in refer-ence and hospital-based labs doing clini-cal diagnostics or research. They may also specialize as cytotechnologists, his-totechnologists or pathologist assistants (PA.) The job of a PA is similar to that of a physician’s assistant, except the PA works under a medical pathologist. For example, they perform gross examina-tions and dissect tissue.

What are the hazards?The type of histopathology specialization will determine the types of hazards. For example, employees who handle fresh tissue, such as lung biopsies, may be exposed to Mycobacterium tuberculosis (TB,) Hepatitis B or HIV, and histotechnol-ogists may suffer upper extremity injuries and microtome lacerations during tissue sectioning. All specialties involve biologi-cal, chemical, physical and psychological hazards. Infections risks are of particular importance.(Andrion & Pira, 1994) Some

of the agents of concern are TB, Hepati-tis B and C, HIV and Creutzfeldt-Jakob. In terms of chemical hazards, formalde-hyde and xylene(s) appear to be most important.(Roy, 1999) Other concerns include: alcohols, aromatic amines, methacrylates, glutaraldehyde and latex. There are some unusual risks involving tissue preparation, such as exposure to picric acid and stains containing silver or mercury. Physical risks include sharps injuries, musculoskeletal disability from repetitive motions, accidental fi res, ra-diation, and exposure to liquid nitrogen and other cryogenic agents. Repetitive motion injuries are a particular problem given the fast pace and high work vol-ume in this department. Finally, as in any job involving tight time constraints, psy-chological stress may be a problem.

Exposure routes for hazardous agents can be dermal or respiratory, with inhala-tion as the most signifi cant risk. While inhalational risks are more common and can often permit higher amounts of the chemical to enter the body, avoid down-playing the dermal risk because a prob-lem could occur if adequate attention is not given to skin protection.

ControlsThe creation and maintenance of a safe work environment has been recognized by the American Society for Clinical Pa-thologists as an important part of good quality assurance management, includ-ing patient safety (http://www.ascp.org/.) Having well trained and certifi ed staff is critical in achieving this safe en-vironment. Training in lab safety is an important part of the continuing educa-tion requirements for each of the spe-cialty areas. Good design and effi cient equipment are also keys to workplace safety.(Andrion et al., 1994) Part of good design includes an effective ventilation system. According to the American In-stitute of Architects, histology and pa-thology labs should have a minimum of six room air changes per hour.(AIA, 2001) However, in histopathology, toxic chemicals such as formaldehyde and xylene are most effectively captured using a local exhaust LEV system, and failure to use an effective system could result in signifi cant exposures.(Edwards & Campbell, 1984) The key to an effec-tive LEV system is to have the hazard source as close to the hood opening as possible (and ideally within a fume hood for gases and vapors, or a biological safety cabinet for microorganisms.) It is

All product information is not endorsed by the author or AOHP but merely is a resource for individuals.

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also important to place LEV units in loca-tions that avoid cross currents that can interfere with capture. The face velocity of these hoods should be checked annu-ally to assure a minimum of 100 to 150 cfm/ft2.(ACGIH, 2007)

While less preferred than ventilation or other engineering controls, respiratory protection is at times the best or only method for protecting workers in labora-tory situations. For example, respirators may be necessary when engineering controls have not been implemented, are not economically feasible or when some operation must be done and controls are being repaired. If respiratory protection is used, a full respiratory protection program is required following the OSHA respira-tory protection program in 1910.134. The evaluation of the histopathology environ-ment and determination of needed con-trols and programs are best addressed by using a certifi ed industrial hygienist.

References

ACGIH (2007.) Industrial Ventilation - A Manual of Rec-ommended Practice for Design. (26th ed.) Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

AIA (2001.) Guidelines for Design and Construction of Hospital and Health Care Facilities. Washington, D.C.Andrion, A. & Pira, E. (1994.) What’s new in managing health hazards in pathology departments. Pathol.Res.Pract., 190, 1214-1223.

Edwards, F.P. & Campbell, A.R. (1984.) Removal of formaldehyde and xylene fumes from histopathology laboratories: a functional approach to the design of ex-traction systems. J.Clin.Pathol., 37, 401-408.

Roy, D.R. (1999.) Histology and pathology laboratories. Chemical hazard prevention and medical/health surveil-lance. AAOHN.J., 47, 199-205.

AOHP Web site Coordinator

AOHP is seeking a member to regularly review content of the AOHP Web site to ensure accu-racy and timeliness of content. If you are interested, please contact

AOHP Headquarter, 800 362-4347, or email info@aohp.org.

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Talking Points Healthcare Ergonomics

This issue’s Talking Points in Healthcare Ergonomics column features an article from a Clinical Consultant with Diligent Services, Esther Murray. Ms. Murray has worked for more than four years as a Diligent Nurse Consultant, working with hospitals and nursing homes to establish safe handling programs and providing ongoing guidance for those facilities on the compliance of their safe patient han-dling programs. Prior to her position with Diligent, Esther gained several years ex-perience as an Employee Health Nurse during the time of Bloodborne Standard implementation.

What? Me? A change agent ??? I don’t even have the courage to change my hairstyle! How can I help others to change?

Safe patient handling and transport is a major area of change permeating health-care workplaces over the past several years. Implementing compliant behav-iors has been more complicated than simply identifying and shipping the ap-propriate equipment. Caregivers (and their attitudes toward manual lifting) have been seen to be an equally essen-tial element of minimal lift programs. Their willingness to embrace change is often a critical factor in determining the rate and ultimate success of lift pro-grams. Those overseeing the implemen-tation process must understand their role goes beyond procuring equipment and dictating training schedules: they must become change agents to improve the likelihood of a success for the pro-gram in their facility.

In small, incremental ways, every day the occupational health professional (OHP) helps others change. During rou-tine employee exams, the health history is reviewed, the physical is done and discussion commences about the out-comes. Suggestions about small chang-es may include: “An extra glass of wa-ter at lunch will help in weight loss,” or “Eat celery sticks at break time instead of taking a smoke,” or “Walk the stairs instead of taking the elevator.” In many areas, small, incremental changes, done over time, yield big results.

A change agent, by defi nition, is a per-son who:

Leads a project or initiative that cre-ates a change in the “way things are done around here.” Defi nes how the change will be im-plemented.Defi nes the reality of what’s in-volved in the change, regardless of the popularity of the change.Selects and identifi es who and what is needed for the change to be suc-cessful.Troubleshoots challenges through-out the change process.1

How does the OHP assist the organiza-tion in being a change agent? Remember the project of implementing the Blood-borne Pathogen Standard (BBPS?) The process of implementing all the changes the regulation required was often mobi-lized by the OHP. The implementation of the BBPS was the single largest change in healthcare to date. Using a barrier for every interaction involving the POSSI-BILITY of body fl uids was a tremendous change in routine, to say the least!

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When the training started, the arrows began to fl y. “WHAT! Wear gloves ev-ery time there’s an IV to start?” Resis-tance to change was coming from all sides. The price of gloves was too high; there would never be enough. Giving care could not be accomplished with a gloved hand. Seriously, what is the im-pression from those objections today? There may not be 100 percent compli-ance today, but it is much higher than when training began 15 years ago.

Behavioral change related to implement-ing the BBPS took months. Immuniza-tion clinics were made available to all employees. Flyers were sent to all de-partments, articles were placed in the hospital newsletter, announcements were made in all staff meetings, etc. The concern for safety was palpable, the urgency to get immunizations was frenzied and the documentation was es-sential. Whenever the OHP was out and about, questions arose about the partic-ulars: “What about the titer? When’s the next immunization clinic? How will a de-partment get heavier gloves or non-latex gloves?” Eventually, every employee was trained about the procedures and given access to gloves and other equip-ment.

Change happened, slowly. Today, walk-ing the halls of any medical establish-ment, clinic, hospital, nursing home or lab, gloves are readily visible – in several sizes, and in different types depending on the department. Goggles, the moon-suit and other barriers are available just for the asking. Change happened, word is out and health care employees know the process in and out. They are quite

All product information is not endorsed by the author or AOHP but merely is a resource for individuals.

The Occupational Health Professional as a Change Agent

By Esther Murray, RN, COHN-SClinical Consultant, Diligent Services

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conversant on protection, both pro and con.

The BBPS implementation was accom-plished by the Safety Committee where I worked as an OHP. No one worked alone, but there was a job – a process – for everyone to organize and work out. The meetings were frequent, and reports were distributed weekly to keep administration informed of our progress. This implementation riveted my atten-tion to the potential of being a change agent by employing the management theory called “management by walking around (MBWA.)”

Small positive changes, brought about over time, are benefi ts of MBWA. This theory was popularized in the book by Tom Peters titled “In Search of Ex-cellence.” The manager who “walks around” and spreads a posi-tive word, looks at what is go-ing on, and rewards positive behavior, ultimately changes behavior just by being around.

Industry has used the practice of MBWA, and IT departments employ the strategies with suc-cess. Elements of the MBWA style are found in a wide vari-ety of work settings. Recently, there has been nursing litera-ture from the UK advocating nursing walking rounds twice a shift as a strategy to increase client satisfaction and reduce patient falls! The charge nurse walks the unit to get an overview of patient condition. In the two articles reviewed, even the number of call lights was dramatically reduced. Vis-ibility goes a long way in deter-ring dissatisfaction and “dan-gerous” or unsupervised activity.

What does this have to do with OHPs changing anything? Get a group of OHPs together, and the issue of having responsibility without direct authority al-ways comes up. The Employee Health Nurse/OHP sees the position as one with little or no power. Yet the OHP is one of the few staff members given the

opportunity to see and talk to everyone from the top to the bottom. After all, as ‘their nurse’ or ‘their caregiver,’ there is a direct relationship. The OHP has a unique ability to move freely throughout the entire hospital with a reason to be everywhere!

Safe Patient Handling programs or minimal lift programs have once again pushed many OHPs into the front of the change process.

In recent years, many facilities have ini-tiated no-lift policies, and some states have passed laws requiring hospitals to establish and implement programs on safe patient handling. In January 2006, Texas became the fi rst state to enact such legislation; it requires medical fa-cilities to establish protocols “to control risk of injury to patients and nurses asso-

ciated with the lifting, transferring, repo-sitioning or movement of a patient.”3

Also, in 2003, the American Nurses As-sociation launched its Handle with Care campaign, “a profession-wide effort to prevent back and other musculoskeletal injuries” (see www.nursingworld.org/handlewithcare.) It released a position statement, Elimination of Manual Pa-

tient Handling to Prevent Work-Related Musculoskeletal Disorders (see www.nursingworld.org/readroom/position/workplac/pathand.pdf.) 4

And, in September 2006, a bill was in-troduced to the U.S. House of Repre-sentatives, the Nurse and Patient Safety and Protection Act of 2006 (HR6182), that will, if passed, “amend the Occu-pational Safety and Health Act of 1970 to reduce injuries to patients, direct-care registered nurses, and other health care providers by establishing a safe patient handling standard.”5

The safety and health of the healthcare worker is the mission of the Employee Health Nurse /OHP. With that focus, the OHP should be at the forefront of the safe patient handling program. It doesn’t have to be an OHP program, but be in-

volved and get informed about safe patient handling. It’s not just about patients. This is the time to bring together the passion for employee safety with the unique ability of the OHP to act and infl uence all levels of the organization.

I offer the following suggestions for “change agent implementation” of a safe handling program:

BE AVAILABLE / BE VIS-IBLE: Walk the halls, even if you can only walk a few units each week. Plan time to be out, and time to stop for questions.

GO ALONE: Staff are more inclined to approach you if you are alone.

ENCOURAGE: Reinforce positive behaviors. Catch people doing the right thing.

ASK: everyone. What lift has been used today? What is the most fa-vorite lift? When was the last time you used a lift? Who are the coach-es on this unit?

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Twelve Guidelines for Managing By Walking Around (MBWA)

summarized by futurecents.comDo it to everyone.Do it as often as you can.Go by yourself.Don’t circumvent subordinate managers.Ask questions.Watch and listen.Share your dreams with them.Try out their work.Bring good news.Have fun.Catch them in the act of doing something right.Don’t be critical.2

1.2.3.4.

5.6.7.8.9.10.11.

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VALIDATE: complaints, problems, concerns. Follow through with the answer. If you don’t know, fi nd someone who does. Staff need to be heard and validated in their con-cerns.

TALK IT UP: Guide conversations with staff to the current status of the program - the goals and objec-tives. Let them know how they can support the lift program.

MODEL: Offer to show staff how to use the lifts and other assistive tools on their ‘turf.’

RECOGNIZE and REWARD: compli-ant behavior. When observed us-ing proper equipment or when lift assessments are completed, offer tangible recognition or rewards.

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ACCEPT: that not everything will go smoothly. There will be bumps in the change process. This is an opportunity to improve processes within the organization that may not be working.

EMPATHIZE: Change takes time. Direct care staff will be challenged to change the deeply ingrained habit of manual lifting. Utilizing a tool to move a patient will not be the FIRST thought for healthcare workers for awhile.

BE POSITIVE: Change will happen. Mechanical lifts make the work of moving patients much easier. Staff will, after using the lifts, convince each other that the lifts will make their lives easier and their loads lighter.

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OHPs can be effective change agents in instilling a safe handling program for their employers. To quote Margaret Mead, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

References

1. Cohen, Shelley, “Change agents bolster new prac-tices in the workplace.” Nursing Management, June 2006, pp 15. Springhouse, Corp.

2. http://www.futurecents.com/mainmbwa.htm ac-cessed 8/6/07

3. Jacobson, Joy. “Recent Policy and Legislative Initia-tives, Will ‘no manual lifting’ policies become a national norm?” American Journal of Nursing, Vol. 107, no.8, pp 55.

4. ibid.

5. ibid.

15

Fall 2007

Ready to ResearchBy MaryAnn Gruden, CRNP, MSN, NP-C, COHN-S/CM –Column Editor

The purpose of this article is to share the experience of one AOHP chapter as it formed a Chapter Journal Club. “Tid-bits of Wisdom” for starting a Journal Club and several ex-amples of practice issues that were and will be addressed using the Journal Club format will be discussed.

Step One: Sparking In-terest The fi rst step in starting a Chapter Journal Club is to spark interest among the members! Many of us par-ticipate in research-type ac-tivities on a daily basis, but the very word RESEARCH may be frightening and over-whelming to some.

Interest in research can be easily sparked if there is an unfamiliar clinical practice is-sue that must be addressed. Spark interest in the research process by networking with other healthcare profession-als about current practices. Call a colleague or a chapter member and seek advice. A

perfect setting for network-ing is an AOHP chapter meet-ing using the Journal Club format.

When questions arise about best practice, review the current nursing and related research. An example would be possible questions related to respirators and fi t testing. These questions might in-clude: Is annual fi t testing for N 95 respirators being con-ducted? Are powered air pu-rifi ed respirators more effec-tive and safer for employees to use? Is the organization in compliance with the OSHA respirator standard? Is there research that supports annual fi t testing of respirators?

The internet is a powerful tool to gather information and research fi ndings related to practice issues. A wonderful Web site to search regarding the respirator question is the Centers for Disease Control and Prevention National Insti-tute for Occupational Safety and Health (NIOSH) Web site

at http://www.cdc.gov/niosh/npptl/topics/respirators/. This site provides guidelines/rec-ommendations and reviews related material. Finding the right Web site increases the clinician’s ability to remain current with practice guide-lines, especially if chapter members share in research-ing new information or guide-lines.

Step Two: Light the FiresAs a national Executive Board Member, I listened to the Board’s discussion regard-ing starting Journal Clubs and had to admit, I was not certain about what a Journal Club was or what it involved. A Journal Club is simply a group of professionals dis-cussing a published research article. The goal of a Journal Club is to review research fi ndings using critical think-ing skills. After review of the fi ndings, determine whether or not the fi ndings need to be implemented to improve out-comes for a patient popula-tion. In the case of the occu-

MaryAnn GrudenColumn Editor

It is a pleasure to introduce Lynne Karnitz as the author for this column. Lynne is the Employee Health and Wellness Coordinator for Aurora Medical Center, Two Rivers, Wisconsin and Aurora Health Centers, Manitowoc County. In addition to managing the employee health and wellness initiatives for Aurora Health Care Manitowoc County, she serves as the AOHP Region 2 Direc-tor. Lynne has more than 33 years of experience in the healthcare setting and is a certifi ed occupational health nurse. She is an active AOHP member who has been involved in a variety of activities. In addition to her responsibilities as Region 2 Director, she is also a member of the AOHP Research Committee. Her research “Sharps Injury Data Collection and Injury Prevention in a Multi-Hospital System” was published in the AOHP Journal, Summer 2003. Dedicated to improving processes, research is one of her passions.

Sparking Interest in a Journal ClubBy Lynne Karnitz, RN, BSN, MS, COHN-S

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pational health professional in healthcare, our patient popula-tion is the facility’s healthcare workers. Implementation of research outcomes leads to evidence-based practice and improved outcomes. This ap-proach made sense to me!

As Region 2 Director, I vol-unteered my chapter, Wis-consin, to be a pilot for the Journal Club. My goal was to “light the fi res.” In order to “light the fi res,” a topic needed to be identifi ed, the research needed to be con-ducted, the research fi ndings needed to be shared and the application to practice needed to be identifi ed.

Step Three: Select a Topic/Question of Inter-est in Daily Clinical PracticeThe topic or question to be researched can be a “burning issue” or simply one that you are not certain how to handle. Are the policies and process-es now in place meeting the current standards and recom-mendations? Do they need updating? Remember, the goal of a Journal Club is to review research with subse-quent implementation of fi nd-ings to improve outcomes.

In our chapter, for example, several members were un-sure of how to best to meet the needs of employees with multiple sclerosis (MS.) At my worksite, there were both a hospital-based and a clinic-based employee who were di-agnosed with MS. Both were full-time employees, mothers with small children who had demanding work schedules. While discussing this issue with a colleague, she shared her personal challenge of deal-ing with a parent who had MS for most of her adult life.

The concern and question was “How could the needs of employees who have MS be best accommodated?” Are we doing everything to ensure a safe work environ-ment and to ensure that safe patient care is being pro-vided? Could we integrate the lessons learned from our colleague who cared for her mother and transfer those “pearls of wisdom” to assist the employees?

Step Four: We Are Lit!Using the Journal Club for-mat, we decided to research the topic, share the research fi ndings and review the pro-cesses in place at the work-sites for job accommodations. We used a search engine and reviewed current nursing journals to fi nd articles that addressed our concerns.

Articles related to Journal Clubs and MS were mailed (or distributed) to the chap-ter members. The article in the AOHP Spring 2006 Jour-nal related to Journal Clubs by Jeanne Clancey provided introductory information, in-cluding the purpose of Jour-nal Clubs and guidelines for critically reading nursing re-search. Members were asked to read the articles before the meeting, using these guide-lines to facilitate group dis-cussion. Members were mo-tivated because they knew that doing a literature search, reviewing the research and having a discussion at the chapter meeting would aid us in answering the questions that were posed.

Two major biomedical data-bases that were searched were MEDLINE and the Cu-mulative Index for Nursing and Allied Health Literature (CINAHL.) It is recommended

that members check with the facility’s medical librarian to learn whether or not they have access to these and oth-er related databases at work. More information about lit-erature searches is included in the AOHP Fall 2006 Jour-nal article by Mary Jo Dorsey. In addition, if members are interested in brushing up on nursing research, a list of re-search references has been developed by the AOHP Re-search Committee. These references are not inclusive, yet are excellent resources related to nursing research and are included as a sepa-rate section in this article.

Step Five: Keep the Flame BurningI facilitated group discussion at the meeting, following the guidelines mentioned above for critically reading nursing research. Each mem-ber gave a synopsis of what they learned when review-ing the articles. I prepared and presented a Power Point presentation that reviewed the essentials of reading re-search, abstract review and benefi ts of the article review. Next, we focused on input from other members that had employees with MS. Another member provided insight into helping a family member deal with MS. A wonderful dis-cussion followed, with many examples of how we could provide the employees with necessary accommodations to continue working.

Other issues that surfaced during the discussion in-cluded Family Medical Leave and Americans with Disabili-ties Act (ADA) compliance. Helpful Web sites for up to date information on these is-sues include http://www.dol.gov/dol/topic/benefi ts-leave/

fmla.htm for leave informa-tion and http://www.usdoj.gov/crt/ada/adahom1.htm for information on the ADA. Another useful resource for job accommodations is the NIOSH Job Accommodation Network, at http://www.jan.wvu.edu/links/adalinks.htm.

When professionals partici-pate in Journal Club, clinical practice changes can be implemented that are sup-ported by research fi ndings. In addition, as professionals, we will be challenged to ex-amine current practices more closely and make changes. Often, answering one ques-tion leads to other questions.

Step Six: Lessons Learned What did we learn about indi-viduals with MS that could be applied to the worksite and clinical practice? Easy fi xes such as improved lighting and computer glare screens may be helpful to accommodate vision problems. Page turn-ers, book holders, a small cart to transport supplies, fl exible scheduling, special parking considerations and reducing sensitivity to heat by ensur-ing a cool environment are simple, yet effective ways to assist employees with MS in the work setting. Clinical nursing interventions include annual fl u vaccination, weight reduction classes, if indicat-ed, and encouraging routine screenings. Offering a modi-fi ed environment where staff can feel productive and com-fortable within their physical capabilities will yield a safer work environment and safe patient care.

Summary: Moving ForwardTraditionally, our July chapter meeting has been one where

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Fall 2007

we relax and share best prac-tice processes. The plan for this July’s meeting was to review literature regarding an issue that is near and dear to my heart, the aging work-force. The rationale for this topic is that by the year 2010, 40 percent of all registered nurses will be in the category of “older nurses,” defi ned as 45 years of age or older. Ar-ticles will include implications for health care organizations, helping employees navigate through midlife, and “The Oldies are Goodies,” or What does the experienced nurse bring to the practice setting? I planned an update on cur-rent practices and how we can best meet the needs of the older worker.

The Wisconsin Chapter mem-bers have been very excited and involved in the Journal Club. Sue Zduan, a Wiscon-sin Chapter member, stated, “The experience has been very gratifying. I learned so much that I can apply to my practice right now.” Our goal is to keep the fi res burning and add research as an agen-da item at our meetings. Journal Clubs allow us to re-main current in our specialty practices and share some of the responsibility of remain-ing current. As professional nurses, we are held account-able to use evidence-based practice in our clinical set-tings. Journal Clubs are one method that can be used to accomplish this goal.

Journal Clubs are also fun. Just ask any Wisconsin Chapter member, “What is your ‘burning’ question? Did I spark your interest?”

References

Clancey, Jeanne K. (2006.) Journal Clubs: Bringing Research to Our Clini-cal Practices. Journal of the Association of Occupational Health Professionals in Healthcare, Vol. XXV1, Number 2, 16-18.

AOHP Research ReferencesBooks/Book Chapters

Dicenso, A. et al. (2000.) Evidence-based nursing: past, present and future. EBN Online. Retrieved 2/4/05. 3:7-8.

DiCenso, A., Guyatt, G., & Ciliska, D. (Eds.) (2005.) Evidenced-Based Nursing: A Guide to Clinical Practice. St. Louis: MO: Elsevier Mosby.

Flemming, K. (1998.) Asking answerable questions. EBN Online. Retrieved 2/11/05. 1:36-37.

Houser, J. & Bokovoy, J. (2006.) Clinical Research in Practice: A Guide for the Bedside Scientist. Boston: Jones and Bartlett Publishers.

Lockhart, J.S. ( 2004.) Unit-Based Staff Development. Pittsburgh, PA: Oncology Nursing Society.

Nicoll, L.H. (2001.) Nurses Guide to the Internet. 3rd edition. Lippincott, Williams and Wilkins, Philadelphia

Oman, K.S., Krugman, M.E., & Fink, R.M. (Eds.) (2003.) Nursing Research Secrets. Philadelphia, PA: Hanley & Belfus, Inc.

Polit, D.F., Beck, C.T., & Hungler, B.P. (2001.) Essentials of Nursing Research: Methods, Appraisal and Utilization. (5th ed.). Philadelphia: Lippincott.

Rubenfeld, M.G. & Scheffer, B.K. ( 2006.) Critical Thinking Tactics for Nurses. Boston: Jones and Bartlett Publishers.

Rosswurm, M.A. and Larrabee, J.H., (1999.) A model for change to evidence-based practice. Image: Jour-nal of Nursing Scholarship. 31(4), pp 317-321.

Wood, M.J. & Ross-Kerr, J.C. (2006.) Basic Steps in Planning Nursing Research. (6th ed.) Boston: Jones and Bartlett Publishers.

Yoder, L.H., (2005.) Evidence–based practice: The time is now. MEDSURG Nursing. 14(2), pp 91-92.

Journals

Journal of Nursing Scholarship. An offi cial publication of Sigma Theta Tau International Honor Society of Nursing. Blackwell Publishing, Malden, MA – Quarterly.

Nursing Research. Offi cial Journal of the Eastern Nursing Research Society and Western Institute of Nurs-ing. Lippincott, Williams and Wilkins, Hagerstown, MD. www.nursingresearchonline.com – Bimonthly

Nursing Science Quarterly: Theory, Research and Practice. Sage Publications, Thousand Oaks, CA. Devot-ed to the enhancement of nursing knowledge; major purpose to publish original manuscripts focusing on nursing theory development, nursing theory-guided practice, quantitative and qualitative research related to existing frameworks.

Web Links

http://www.hsl.unc.edu/Services/Tutorials/EBN/index.htm

http://www.mclibrary.duke.edu/training/cinahlovid

http://www.hscl.ufl .edu/help/CINAHL/index.html

http://www.acestar.uthscsa.edu/Competencies.htm

http://www.lias.psu.edu/instruction/ebpt/index.htm

http://www.uic.edu/depts/lib/projects/ebphn/index.html

Fragala, Guy. (2006.) Understanding the Process of Research. Journal of the Association of Occupational Health Professionals in Healthcare, Vol. XXV1, Number 3, 12-13.

Dorsey, Mary Jo. (2006.) Searching the Literature: An Evidence-Based Ap-

proach to Clinical Practice. Journal of the Association of Occupational Health Professionals in Healthcare, Vol. XXV1, Number 4, 13-15.

Huycke, LaRae I. (2006.) Multiple Scle-rosis-What Occupational Health Nurses Need to Know. AAOHN Journal, Vol.54, No.11, 469-478.

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Spotlight on an AOHP StarDeb Rivera

This issue of the Journal proudly recognizes three outstand-ing members, Deb Rivera and Jan Wesselmann of the newly formed Heart of America Kansas City chapter, and Maitine Ri-vera of the new Houston chapter.

Lynne Karnitz, Region 2 Director, nominated Deb, Jan and Maitine. Lynne tells us, “Deb and Jan worked diligently with me to form the chapter in their area. Without their enthusiasm and hard work, the chapter would not have become a reality. I salute them for their persistence, dedication and teamwork to form a chapter. I worked with Maitine to form the Hous-ton chapter. She displayed the same inspiring enthusiasm and dedication while working with me to make that new chapter a reality. All three nurses are dedicated to enhancing their nursing practice and that of their peers. All three inspire other nurses to ensure best practice. They refl ect the spirit of volun-teerism, which is at the heart of all we do in AOHP.”

Deb Rivera, RN, COHN, has been the Occupational Health Nurse Supervisor for Children’s Mercy Hospitals and Clinics in Kansas City, Missouri and Overland Park, Kansas for almost nine years. She supervises the occupational health services for more than 500 employees and 1,000 volunteers. Deb iden-tifi es education and individual interaction with employees and volunteers as “favorite duties,” as well as development of new policies and processes, and data analysis and reporting.

Deb has been an AOHP member for eight years, since attend-ing “Getting Started” in Chicago. Deb credits that “Getting Started” with providing her a great starting point as she en-tered the world of occupational health. Interestingly, Deb’s new occupational health nurse participated in the St. Louis “Getting Started” this year, where Deb served as one of the faculty. Talk about full circle!

“AOHP is THE premium resource for information regarding oc-cupational health in the workplace. Of special note is the list-serv. It provides an exchange of information, documents and

experiences that are immeasurably important to my practice. Not only do I have the opportunity to seek out the counsel of my fellow colleagues, but it makes me consider and often re-think my practice. AOHP also provides me cutting edge infor-mation and hot-off-the-press articles that I most likely would have missed. It’s an incredible community that I am pleased to see growing. It has been a privilege to be part of this growth,” Deb tells us with great enthusiasm.

Deb shares a great sense of accomplishment in helping estab-lish the new Heart of America, Kansas City chapter, for which she serves as vice president. Admittedly, her “pride and joy” is her brand new granddaughter, Elizabeth Ann, who just ar-rived mid-July.

Jan Wesselmann, RN, BS, PNP, has been the Employee Health/Workers’ Compensation Manager for Shawnee Mission Medical Center in Kansas City, Missouri for the past 28 years. She is responsible for the development and management of the Employee Health and Workers’ Compensation programs, including the employee safety initiatives and education includ-ing latex, safe patient handling, sharps injury prevention and ergonomics. Jan taps the ability to create a program that pro-tects and helps employees as a “favorite duty,” but likes most everything with the exception of not having the number of needed staff.

Jan especially enjoys work-safety initiatives and teaching. She taught in a BSN program for three years, serves on a diversity teaching staff and recently led three seminars on Modifi ed Duty.

“AOHP has provided me the support of a national profession-al organization, political activism, a newsletter, a listserv with questions and answers from all over the country, as well as benchmarking studies,” Jan shares. She is proud to have led the growth of their local hospital employee health group from 15 to 45 members in the past fi ve years. She credits high qual-

Jan Wesselmann

Maitine Rivera

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Fall 2007

ity educational presentations and networking opportunities for this great increase in membership and enthusiasm.

Aside from work demands, Jan enjoys the pleasure of home and church. Knitting, reading, cooking, cookbook surfi ng, good food and cats are real pleasures. Jan also enjoys participating on the preaching and music staff at her church and is a past president and current member of the Merriam Optimist Club. She is the fi rst president of the new AOHP Heart of America, Kansas City chapter.

Maitine Rivera, RN, BSN, set up the Employee Health pro-gram at Clear Lake Regional Medical Center in Webster, Texas in 1991. She has served as Manager, Employee Health Servic-es for this large, 600-bed facility since starting this program.

Maitine has multiple responsibilities in her Employee Health management role, including that which she truly enjoys, meet-ing and interacting with all of the hospital’s employees. She cites developing and implementing safety and wellness pro-grams as favorite responsibilities due to her strong belief in their benefi ts to employees.

A current AOHP member for two years, Maitine also credits AOHP with help early in her Employee Health career. The local Houston group at that time was instrumental in providing sup-port and guidance. In fact, Maitine describes this “lifeline” of AOHP support as the driving force in forming the new AOHP Houston chapter. “By uniting our efforts, I believe that we can become stronger and have a more positive impact on health and wellness initiatives in the workplace,” Maitine shares.

Maitine enjoys health and wellness, fi tness programs, and nutrition and healthy cooking. She especially enjoys the chal-lenge to cook something delicious that is healthy. She also enjoys camping and gardening and is thrilled to be the fi rst president of the newly formed AOHP Houston Area Chapter.

AOHP and this Journal are proud to spotlight all three of these amazing ladies. Your leadership and dedication to Employee Health and AOHP is truly “shining.”

Editor’s note: Do you know a member to spotlight? You can download the nomination form on AOHP’s Web site, http://www.aohp.org/membership/SpotlightOnStar.asp.

Mark Your Calendar and Come Join Us at the “Mile High City”

in September 2008!

CALL FOR SPEAKERS FOR 2008 AOHP CONFERENCE

Come to join us in September 2008 to experience, explore and discover how the Mile High City will awaken your senses like nowhere else.

AOHP 2008 National Conference • September 17 – 20, 2008

The 2008 AOHP Conference Committee will send an offi cial call for speakers. AOHP re-serves the right to review and accept only those proposals deemed suitable for the program. The conference committee will review all valid submissions. The choice of a session will be based on the presentation of the session, its value to professionals, the location of the speaker (so as to promote local experts), and completeness of the required information submitted. Submitters will be contacted individually about their submission, and will be notifi ed if it was accepted or not.

Session speakers are asked to participate on a “gratis” basis. Speakers receive FREE registra-tion for the day of their presentation and complimentary one-night hotel stay. To discuss alter-native speaker compensation, please contact Dana Jennings, AOHP 2008 Conference Chair, at (303) 789-8491 or occupationalhealth@craighospital.org. Maximum 4 speakers for workshops and 2 for sessions.

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Colleague Connection

Report on The Joint Commission Liaison Forum

By Betsy Holzworth, RN, COHN-S

I had the privilege of representing AOHP at The Joint Commission Liaison Forum on July 10 -11 in Oak Brook Terrace, IL. I don’t know about you, but anything Joint Commission related just makes my heart pound, palms sweat and knees knock. I’ve been through two surveys since taking my position as Employee Health Nurse, and we’re due for the unannounced survey anytime from Oct 2007 through May 2008. Yikes! So, I cau-tiously approached this opportunity to view “the Commission” from a different perspective.

The fi rst day, President Dennis O’Leary started the forum with an overview of the direction of The Joint Commission (TJC.) Mr. Leary stated that less than 1,500 hospitals are accredited, and the number of accreditations has decreased over the years.

TJC has branched out into the interna-tional arena. They have been approached by a number of facilities for accreditation. They have now accredited 130 hospitals internationally and have 113 surveys scheduled for 2008. TJC is currently working on international standards to in-clude: physical plant, patient rights and medical staff. This had me considering volunteering as a surveyor if they were heading somewhere in the tropics!

President O’Leary also explained the new marketing campaign, including branding and tag lines; boy does that all sound familiar. The new tag line is “Helping healthcare organizations help patients.” TJC is also looking into partnering with disease entities (i.e., diabetes, stroke, etc.) to help make patient safety a norm.

Another speaker from TJC discussed the survey process. Unannounced surveys will be conducted 18-39 months after the

organization’s previous full unannounced survey. The data from the Priority Focus Process (PFP) will determine when an organization will have its survey. Poorer performing organizations will be sur-veyed earlier than better performing or-ganizations.

The PFP is a data-driven tool that helps focus survey activity on issues most rel-evant to patient safety and quality of care at the specifi c healthcare organization being surveyed. The PFP does not imply that priority areas are out of compliance or defi cient in any way; rather, it lends consistency to the surveyor’s on-site sampling process. The data is analyzed, and facilities with the larger PFP point totals are the facilities that will get sur-veyed. For example, a facility that was surveyed in January 2006 would have the next regular survey due in January 2009. However, review of that facility’s PFP data may suggest an earlier survey may be indicated, and this could be done in January 2008.

Information about what facilities are be-ing surveyed is posted on TJC Web site at 7:30am in appropriate time zones. It is recommended to check the Web site the morning of the survey for PFP, ORYX information, agenda, introductory letter and bios. When the surveyors arrive, ask to see their ID badges. When in doubt or if the notifi cation is not posted on TJC’s Web site, call the account representative at 630-792-3007.

The Top 10 Challenging Environment of Care Standards for Hospitals in 2006 Were:

NPSG 2, EP2B – Improve effective-ness of communication among care-givers. Use of abbreviations is not permitted.NPSG 8, EP8A – Implement a pro-

1.

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cess for obtaining and documenting a complete list of the patient’s cur-rent medications upon admission. NPSG 8, EP8B – Communicate the patient’s list of medications when the patient is discharged or trans-ferred. NPSG 2, EP 2B – Read back orders. UP – Universal Protocol for prevent-ing wrong site, wrong person, wrong procedure. MM 2.20 – Medication storage. EC 5.20 – Life Safety Code. MM 3.20, EP 13 – Policies and pro-cedures regarding medication orders are implemented. EC 1.10, EP 4 – The organization conducts comprehensive, proactive risk assessments. PC 8.10 – Pain is assessed.

Outcomes from 2006 Surveys:Average number of non-compliant standards for hospitals -7.1Average number of cited Elements of Performance – 10.3 Conditional accreditation rate- 4.2%Pending Preliminary Denial of Ac-creditation -1.0% Accredited rate without any Require-ments for Improvement (RFI) - ap-proximately 3%Rate of organizations receiving at least one RFI - 92%

I thoroughly enjoyed representing AOHP at this conference. It was very informa-tive, and I left this meeting with much less apprehension of and a greater ap-preciation for TJC. For more information on TJC, visit http://www.jointcommis-sion.org/.

Betsy Holzworth, RN, COHN-S, is the Employee Wellness Nurse for Culpepper Regional Hospital in Culpepper, Virginia and the current AOHP Virginia Chapter President.

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Fall 2007

AOHP is Proud to Announce the Recipients of the Association’s Awards for 2007

Joyce Safi an Scholarship AwardLynne Karnitz, RN, BSN, MS, COHN-S

This award is presented to a past or present association offi cer who best portrays an occupational health professional in healthcare role model.

Ann Stinson President’s Award for Association ExcellenceNorthern California Chapter

This Award recognizes a chapter that has demonstrated outstanding performance and enhanced the image of occupational health professionals in healthcare.

Extraordinary Member AwardMary Bliss, RN, COHN

This award recognizes a current association member who demonstrates extraordinary leadership.

AOHP Business AwardAurora Medical Center Manitowoc County

Children’s Medical Center – DallasLiko North America

This award recognizes businesses that support the occupational health professionals and their membership and participation in AOHP.

Sandra Bobbitt ScholarshipAnna Hook, RN, BSKim Twisdale, RN

Jo Ella Waugh, LPN

This award honors current qualifying members with complimentary attendance to the national conference.

Newin 2007!

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Colleague Connection

Hand Hygiene Basics for the Healthcare Worker

By Dee Tyler, RN, COHN-S, FAAOHN

Hand hygiene includes hand washing with soap and water or use of a water-less, alcohol-based hand rub, as well as special attention in caring for the condi-tion of the hands. Since hand washing has long been considered one of the most important infection control mea-sures for preventing healthcare-associ-ated infections, it is no wonder that so many healthcare workers experience problems with their hands.

Our skin is constantly exposed to the elements, making it susceptible to a va-riety of problems. Dermatitis is a com-mon condition of the skin and seen often in healthcare workers due to workplace exposures to gloves, cleansers, chemi-cals and mechanical irritations such as the physical washing of the hands. Ev-ery year, more than 15 million people in the United States visit a doctor because of a skin rash, such as dermatitis. During 1972–2001, NIOSH reports that the num-ber of workplace skin diseases and disor-ders ranged from a peak of 89,400 cases in 1974 to a low of 38,900 in 2001.

Dermatitis, also called eczema, is an in-fl ammation of the skin. It can have many causes, such as health conditions, aller-gies, genetic factors, physical and men-tal stress, and irritants. Some forms of dermatitis include contact dermatitis, neurodermatitis, seborrheic dermatitis, atopic dermatitis, stasis dermatitis and periorial dermatitis. Generally, dermatitis describes swollen, reddened and itchy skin. It’s not life-threatening, and it isn’t contagious. But it can make you feel un-comfortable and self-conscious.

Dermatitis and its symptoms are gener-ally treated with a combination of self-

care steps and medications; however the best way to deal with dermatitis is through prevention.

Prevention Basics and Treatment Essentials - Good Hand HygieneMinimizing the need to wash the skin without compromising infection control principles is key to prevent skin break-down and to aid in the repair of skin that has been broken.

It is unnecessary for you to wear gloves on a routine basis with every patient or resident encounter (such as passing meal trays;) however, you should wear gloves anytime it is reasonable to anticipate an expo-sure to blood or body fl uids. Wear the appropriate glove for the task. For example, latex examina-tion gloves are not meant to with-stand most detergents and cleans-ers, breaking down when exposed to these substances. A utility glove is a better glove to choose.Minimize hand washings as you are able.Use tepid (neither hot nor cold) wa-ter when washing.Use mild soaps or synthetic deter-gents when your hands break out or become dry and cracked. Choose mild soaps such as Ivory, Dove or Basis that clean without excessively removing natural oils. Soap substi-tutes (synthetic detergents) in bar, gel and liquid forms are less drying than deodorant and antibacterial soaps. Use soap only on your face, underarms, genital areas, hands and feet. Use clear water elsewhere. Soaps and moisturizers can be car-ried in a “fanny pack” for quick ac-cessibility.

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Dry yourself carefully. Brush your skin rapidly with the palms of your hands, or gently pat your skin dry with a towel after bathing.

Re-hydrating the skin is very important and is at the heart of preventing skin breakdown, as well as facilitating heal-ing. All healthcare institutions should consider making hand moisturizers routinely available at hand washing sta-tions.

Use a generous amount of mois-turizers, minimally after each hand washing. This seals in moisture while your skin is still damp. Oil based or creams are most desirable, since lotions can actually worsen dry skin. Pay special attention to your legs, arms, back and the sides of your body. If your skin is already dry, consider using a lubricating cream made for dry skin, such as Eucerin, Cetaphil or Nutraderm. Lubricat-ing creams or Vaseline petroleum jelly can be applied at bedtime and gloves worn to bed.Moisturizers that are petroleum-based should not be used with gloves since this can destroy the barrier that some gloves provide. Use a barrier cream and apply sev-eral times throughout the course of the day.Try wearing cotton glove liners and change them frequently, especially if your hands perspire a lot. You will need to launder them and reuse them.Avoid scratching whenever possible. Cover the itchy area with a dressing, if you can’t keep from scratching it. Trim nails, and wear gloves at night.

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Fall 2007

What we wear can also contribute to skin irritation and will also need special attention.

Dress appropriately. Doing so may help you avoid excessive sweating. Wear gloves outside if the tempera-ture drops below 40 degrees.Wear smooth-textured cotton cloth-ing. This will help you avoid irrita-tion.Avoid other irritants. These include wool carpeting, bedding and clothes, harsh soaps, detergents and clean-ing agents.Wear personal protective equip-ment. This includes gloves, sleeves, mask, face shield and other equip-ment used to prevent contact of substances with the skin. Consider the activities you may be performing that you don’t readily consider as aggravating your hand dermatitis, such as pumping gas

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without utilizing a barrier, like gloves or a signifi cant amount of paper han-dling. Be sure you use the appropriate protective equipment for the job whether at home or at work. See your company policy to determine what is appropriate.

Careful attention to teaching and apply-ing good hand hygiene principles can go a long way in preventing the frequent malady of hand dermatitis from being a nuisance at your facility.

References

American Academy of Dermatology. 15 Million Ameri-can Kids and Adults Are Itchy, Irritable and Exhausted, The Villain is Eczema--- and It’s On the Rise. February 2000. http://www.kidsource.com/health/eczema.skin.html

“Dermatitis/Eczema” Mayo Clinic. December 2005. http://mayoclinic.com/health/dermatitis-eczema/DS00339

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“Improving Hand Hygiene in the Healthcare Setting.” Hand Hygiene Resource Center. July 23, 2007. http://www.handhygiene.org/

United States. Morbidity and Mortality Weekly Re-port. Guideline for Hand Hygiene in Health-Care Set-tings: Recommendations of the Healthcare Infec-tion Control Practices, Advisory Committee and the HICPAC/SHEA/APIC/IDSA, Hand Hygiene Task Force. October 25, 2002/ Vol. 51 / No. RR-16 http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

United States. Worker Health Chartbook 2004, Chap-ter 2: Fatal and Nonfatal Injuries, and Selected Ill-nesses and Conditions, Skin Diseases and Disorders. NIOSH Publication No. 2004-146. October 25, 2002/ Vol. 51 / No. RR-16 http://www2a.cdc.gov/NIOSH-Chartbook/ch2/ch2-11.asp

Deidre ”Dee” Tyler, RN, COHN-S, FAAOHN, is the Director of Medical Management for FinCor Solutions in Lansing Michigan. Dee is a long time member of AOHP, Michigan Chapter, having served the national AOHP board as both Executive Secretary and Exec-utive Treasurer.

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2007 AOHP NATIONAL CONFERENCE

“Another excellent conference – I had a great time!”

“As a fi rst time

conference attendee,

I was very impressed.

It was wonderful

networking with other

nurses and making new

friendships.”

“Conference was informative, well-organized and the southern hospitality

was great. Vendors were also very helpful and informative.”

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Fall 2007

SAVANNAH, GA • SEPT. 26-29, 2007“Everyone did a great job with the conference.

… brought back a great deal of knowledge to share with

our administrative staff, as well as our co-workers.”

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Colleague Connection

Gaining Control of an “Out of Control” Workers’ Comp Program

By Kathy Moss, RN, CPHQ, CPUR

Inheriting a new job with old problems is a common issue among Employee/Oc-cupational Health professionals. In 2006, as the new Employee Health nurse for 1,300 employees, I inherited an experi-ence modifi cation ratio (EMR) that was higher than expected. This number, which contributed to very high workers’ compensation insurance premiums, was based on payroll and loss data from 2002, 2003 and 2004. Because injuries may generate expenses for many years, old cases continue to affect rates for quite a while. Although it would take some time to see a real improvement, I needed to take action right away.

I started by studying old incident reports and pouring over insurance data and loss control runs. This was complicated by the fact that I was dealing with two workers’ compensation carriers, one of which was reluctant to share information. I discov-ered employees in our healthcare system were being seen in record numbers in the Emergency Room or going directly to see a specialist, bypassing the hospital’s own Occupational Health Clinic. Many em-ployees were given days off rather than being accommodated when appropriate.

Our loss control specialist at our workers’ compensation carrier suggested I talk with someone who ran a very good pro-gram. That someone turned out to be a fellow AOHP chapter colleague who was happy to share her expertise with me. Our onsite visit to her successful pro-gram provided some good ideas to get things back in order.

Our loss control specialist also helped identify areas that needed improvement. We found that, like most healthcare fa-

cilities, strains due to patient movement were an on-going issue. With encourage-ment from our workers’ compensation carrier, the panel of physicians was up-dated to include only three primary care providers, one being our own Occupa-tional Health Clinic. Visits to any specialist would be by referral only with prior autho-rization from the insurance carrier.

We then educated employees on the workers’ compensation process. Green folders containing an incident report, panel of physicians and step-by-step in-structions for reporting injuries were dis-tributed to all departments. Employees were reminded they did not need to seek medical treatment just because they fi lled out an incident report. They were also instructed to use the ER only if they truly had an emergency. All others could wait until Occupational Health opened.

I updated the orientation presentation for new employees to include an expanded segment on workplace injuries. I tried to dispel the myth that if it happens in the building, it is covered under workers’

compensation (Virginia state law.) I could see lights go on when the captive audi-ence ‘got it.’ Each new employee is given a handout of the presentation, along with an incident report and panel of physicians form. We are lucky to have a very respon-sive loss control consultant who will gen-erate reports and visits onsite when re-quested. He speaks at department head meetings quarterly, provides supervisory position staff feedback and gives them tools to help the process. I found we often have to remind the audience that we have areas where we expect more injuries and higher cost. I never want to make anyone uncomfortable or point fi n-gers, only share the news.

Employee injuries had been reported to the Environment of Care (EOC, often re-ferred to as the Safety) Committee, but were only numbers in a report. I started a ‘pre-EOC’ group that reviewed every single injury. The group is comprised of the safety director, security director, risk manager, director of Occupational Health and me. I try to keep abreast of every single incident report, physician’s note

LESSONS LEARNED:

Make a plan and set goals. After identifying the issues, we brainstormed ways to correct the problems. We decided to compile folders with all the needed information and forms to report injuries, and presented data to department heads within 30 days. We met that goal and then set another goal to educate our entire staff within the next month. By breaking the process down and setting goals, we were able to move along in a timely manner.

Find a champion or mentor. My AOHP colleague was instrumental in help-ing us see where our problem areas were and giving us suggestions that she knew worked.

Share what you know. It is not enough for one person to recognize trends. Everyone needs to be aware of the trends and work towards resolving them.

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Fall 2007

and medical bill, and I try to always know what is going on. I track who is not able to work full duty, and who is not working, at all times. By discussing each individual occurrence monthly, we are able to ask questions, investigate and make changes while the details are fresh. Now when I report to EOC, I can state not only the number of occurrences, but the correc-tive actions taken, in addition to reporting on any trends.

When a committee is being formed that involves employee injuries, the partici-pants know where they can get data. Be-cause we had a few costly injuries in our dietary department, we were able review data that led to the purchase of slip re-sistant shoes as part of the required uni-form. Employee occurrences involving aggressive patients are also a concern,

and I provided the information to put the issues in focus. It was quite clear that a physical attack from an agitated patient could be very costly. Finally, a patient movement team was formed to gather information and is at a point where we can start investigating safety equipment.

Another important part of the program is what I like to call “Keep them work-ing.” Once an employee can safely make it back to work, but the department can-not make an accommodation, I will work very hard to fi nd the employee a posi-tion that meets the restrictions. Almost every employee can fi le, answer phones or perform simple data entry, and many departments would love to have the extra hands. It is a recognized fact that the longer an employee is out of work, the harder it is to bring that person back.

Compensation for lost wages was a big factor in our high insurance premiums.

We recently learned that our premiums had dropped by almost 20 percent. While our improvements to our workers’ com-pensation program could not take full credit for that savings, it did make us feel like all of our efforts were worthwhile.

Kathy Moss, RN, CPHQ, CPUR, is the Lead Employee Health Nurse for Prince William Hospital in Manassas, Virginia. She has been a member of AOHP, Vir-ginia Chapter for more than two years. Kathy wishes to acknowledge and thank Kim Stanchfi eld of Rockingham Memo-rial Hospital in Harrisonburg, Virginia for her valuable information and guidance on workers’ compensation management.

Critical Competency: Determining and Communicating the Number of Nurses You Must Hire

Joan Ellis Beglinger, MSN, MBA, RN, FACHE, FAAN

The price of inadequate numbers of reg-istered nurses to meet patient care de-mands in hospitals is unacceptably high. On any given day, if demand exceeds the number of available nurses, patients will be diverted elsewhere or, worse yet, they will be accepted into the organization and overextend the nurses who will care for them. The results, threats to patient safety and nurse dissatisfaction, have contributed signifi cantly to the problems we experience in acute care today.

This scenario has played out too many times, in too many hospitals, unneces-sarily, across the country for years. It is being exacerbated by the inability of nurse executives to clearly articulate the difference between the number of full-time equivalents (FTEs) budgeted for the year and the number of nurses that

must be hired to effectively position the organization to cover its peak demand and leaves of absence that will undoubt-edly occur.

The purpose of this article is to provide nurse executives with the tools needed to determine the number of nurses that must be hired to enable the organization to staff at the budgeted hours of care at all times. Nurse leaders must under-stand and articulate these critical con-cepts to provide credible leadership to their nursing organizations.

There are several factors to consider when determining how many nurses must be hired to assure the organization can staff at budgeted levels.

The degree of variability from peak census to low census experienced by the organization.The impact of leaves of absence on the organization.

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Executive Summary

Nurse leaders must understand and articulate critical concepts of budgeting and staffi ng to provide credible leadership to our nursing organizations.Determining the ideal number of nurses to hire on any given unit is as much an art as it is a science.Understanding the relationship between hiring requirements and the budget can lead your nursing organization to achieve important results for your hospital.

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(continued) Gaining Control of an “Out of Control” Workers’ Comp Program

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Average length of stay and corre-sponding daily admission, discharge, and transfer activity.

Nursing budgets are typically developed by multiplying the projected number of patient days for the budget year by the planned hours of care per patient day. The hours per patient day vary by service specialty and are often determined us-ing a combination of benchmarking and practice wisdom. The resulting FTE bud-get refl ects the staffi ng requirements for the average daily census. In an or-ganization in which there is signifi cant variability between the average census, peak census, and low census, hiring at a level equivalent to the FTE budget will leave the organization seriously short during times of peak demand.

ExampleConsider the example of St. Mary’s Hos-pital, a 440-bed tertiary referral center in Madison, WI. The 2007 budgeted pa-tient days result in an average daily cen-sus of 260. During January, there were several days during which the census reached 340. The example calculation below illustrates the importance of ad-dressing the number of nurses to hire as a separate consideration from the total FTE budget.

The average hours of care budgeted per patient day is 10.325 nurses working 8-hour shifts are needed to staff a 24-hour period at a census of 260 (260 patient days x 10 hppd = 2,600 hours/8 hours = 325 nurses).425 nurses working 8-hour shifts are needed to staff a 24-hour period at a census of 340 (340 patient days x 10 hppd = 3400 hours/8 hours = 425 nurses).100 additional nurses are required each 24-hour period the census is at 340 as compared with the average of 260.

A second consideration in determining the number of nurses to hire is the im-pact of leaves of absence on the orga-nization. At St. Mary’s, the past decade has been one of signifi cant growth in the number of employees availing them-

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selves of the benefi ts of the Family Medical Leave Act. In each of the past 5 years, there are, on average, 30 FTEs of leaves of absence in play at any point in time in the nursing organization. At the younger end of the spectrum, nurses in their childbearing years are choosing to expand their families. The baby boomers are experiencing their own health issues and those of their parents. The result is a signifi cant portion of the workforce is unavailable at any given time.

The fi nal consideration in determining the number of nurses to hire is the length of stay, and the corresponding admission, discharge, and transfer activity that oc-curs on any given day. In organizations with relatively short length of stay, the daily activity frequently results in units being full for signifi cant portions of the day, as the incoming patients overlap with those who will be discharged. In our hospital, this has resulted in the need to staff the units for maximum capacity. We are easily able to fl ex down when the census is at less than peak but fl ex-ing up, if inadequate numbers of nurses have been hired, is not possible.

The Signifi canceMany nurse executives are held to hir-ing no more than the budgeted number of FTEs in any budget year. It is impera-tive that we reverse this trend through understanding the relationship of hiring to the ability to meet peak demand and educating our administrative colleagues, as well.

Once understood, it becomes clear why the problem of routine use of temporary nurses has evolved. A nurse executive who is limited to hiring for an average census will never have the staff to meet peak. It is equally clear that the “position control” systems of old make no sense in environments in which there are sig-nifi cant fl uctuations of census. Creating “positions” for each FTE in the budget, for the purpose of controlling hiring, will leave the organization woefully short during times of peak demand.

Determining the ‘Right’ NumberDetermining the ideal number of nurses to hire on any given unit is as much an art as it is a science. In our organization, this is the responsibility of the fi rst-line manager, known as the unit director. Unit directors assume accountability for man-aging each day at their budgeted hours of care per patient day. This is accomplished through fl exing up and down on a shift by shift basis to meet demand. In exchange for their rigorous attention to fi scal man-agement, they are afforded the freedom to determine the number of nurses they must hire to staff according to plan.

Our organization has a budget of about 1,000 FTEs for 2007. Our experience has taught us that we must hire between 50 and 80 FTEs more than budget to as-sure we have the resources needed to meet the daily demands throughout the year. We have established a hiring plan for 2007 that will include about 50 FTEs more than our budgeted 1,000.

ResultsUnderstanding the relationship between hiring requirements and the budget has allowed our nursing organization to achieve important results for our hos-pital. We have never used an agency nurse, a traveling nurse, or mandated overtime. We do not divert patients due to inadequate nurse staffi ng and we are a MagnetAE-recognized nursing organi-zation since 2002. It is critical to the fu-ture health of our organizations that we, as nurse leaders, understand, articulate, and insist upon appropriate numbers of nurses to meet the widely varied staff-ing demands of our hospitals.

Joan Ellis Beglinger, MSN, MBA, RN, FACHE, FAAN, Vice President for Pa-tient Care Services, St. Mary´s Hospital, Madison, WI.

Reprinted with permission, Nursing Economics, March 2007.

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Addressing Multigenerational Confl ict: Mutual Respect and Carefronting as Strategy

Betty R. Kupperschmidt, EdD, RN, CNAA

This article addresses the challenges faced by nurses as they work side-by-side with nurses from a variety of gen-erational cohorts. First a brief overview of the generational characteristics of the four generational cohorts in today’s workplace is presented. Next the impor-tance of each nurse using respect and carefronting as antidotes to generational confl ict is discussed. Finally the role of nursing leadership in facilitating respect and carefronting is noted.

IntroductionThe pervasiveness of multigenerational confl ict in the nursing workforce is seen in the recent number of papers published and sessions presented at professional conferences, as well as Swearingen and Liberman’s (2004) comprehensive litera-ture review using confl ict theory and co-hort theory perspectives. Management literature in nursing and other fi elds con-siders confl ict from the perspective of the manager’s responsibility in dealing with the confl ict. Yet individual employ-ees, such as nurses, also have a respon-sibility to learn to work cooperatively with peers representing generational cohorts different than their own. The challenge to move toward shared ac-countability between professional staff nurses and managers has been issued (Kupperschmidt, 2004). If professional nurses are unwilling to assume shared accountability for creating environments consistent with the values of the profes-sion, i.e., environments that encourage respectful interactions with colleagues, should they continue to assert that car-ing is the essence of nursing? This au-thor argues that professional nurses must care enough about their patients, their profession, their multi-generational

colleagues, and themselves to carefront disrespectful behavior from other pro-fessional nurses.

In this article, examples of confl ict be-tween the four generations comprising today’s nursing workforce, along with characteristics and selected strengths each generation brings to the work-place, are described. Additional litera-ture addressing these characteristics and strengths is readily available in the management literature and elsewhere. Next it is argued that treating each other with respect is the individual nurse’s ethical responsibility. Carefronting, a model of communication used when professional nurses care enough about themselves and their patients to con-front disrespectful behavior face-to-face (Kupperschmidt, 1994), is presented as a strategy to foster mutual respect among professionals who pride themselves on being members of a profession that cares. First, however, a brief review of literature addressing confl ict in the nurs-ing workforce is offered.

Confl ict in the Nursing WorkforceManion and Bartholomew (2004) con-ceptualized effective intergenerational relationships as community, noting that the desire for a sense of community at work, a community in which confl ict is addressed gracefully, is universal. Yet far too often this graceful addressing of con-fl ict is missing in the general workforce including the health care workforce. This lack of peer cohesion and poor working relationships has been noted as a factor in nurse burnout (Garrett & McDaniel, 2001). Bernstein and Fundner (2002/2003) reported that innumerable examples of disrespectful behavior are

both ubiquitous and insidious in their erosion of productive collaborative ap-proaches to patient care among hospital workers. They pointed out it would be naïve to think that noble institutions like hospitals would have any better track re-cord than other complex organizations. Hutton (2006) also reviewed the litera-ture of incivility, defi ned as a violation of workplace norms for mutual respect, asserting that the literature indicates in-civility pervades workplaces, including health care organizations.

Research specifi cally connects confl ict in the workplace with nurse retention. Negative, non-supportive, unpleasant, and uncooperative peers and co-workers are key impediments to nurses’ ability to fi nd joy in their work (Manion, 2003). An-thony et al. (2005) found teams that work together, support one another, and re-solve confl icts are critical factors in staff nurse retention. Strachota, Normandin, O’Brien, Clary, and Krukow (2003) re-ported that employee friendliness and cooperation are listed among the most favorable reasons why nurses stay with their jobs. Sumner and Townsend-Roc-chiccoli (2003) presented a moving pa-per addressing the reasons why nurses leave nursing. They asserted that nurs-es’ intrinsic or existential need to be validated as consummate professionals frequently is not being met; professional nurses need to be rewarded with peer recognition and respect as well as rec-ognition by patients for the special gift of self they give. They cited lack of respect for the gift of self as a cause of the exo-dus of nurses from nursing.

Researchers who have explored work-place stress specifi cally related to gen-

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erational differences have reported con-nections between generational confl ict and workplace stress. Santos and Cox (2000) and Santos et al. (2003) noted marked differences between Boomer and Generation X colleagues’ percep-tions of this confl ict and related stress, with Boomers reporting considerable confl ict with Generation X nurses’ at-titudes and behaviors. Boomers are angered by Generation X nurses’ per-ceived arrogance, lack of commitment, and slacker attitude. However, Genera-tion X staff nurses did not agree with the Boomers’ perceptions of their behaviors. They felt their attitudes portrayed self-reliance rather than arrogance and that their commitment to the profession and the organization was greater than that of the Boomer RNs (Santos & Cox). In another study, newly graduated nurses reported that diffi cult peer relationships, described as lack of acceptance and re-spect, made their transition into the RN role more diffi cult (Casey, Fink, Krug-man, & Propst, 2004). DeMeglio et al. (2005) reported that the novice nurses in their study also described subtle in-stances of lack of professional respect and support. Although a recent national survey of 1,783 RNs reported markedly improving relationships between RNs (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005), generational confl ict is still alive and well among the four genera-tions of nurses in today’s nursing work-force. Lancaster and Stillman (2002) noted that this generational confl ict can be poignant, painfully funny, or just plain painful. In nursing, it is painful and cries out for attention.

Differences Between Generational CohortsPerhaps one of the earliest documented cases of generational confl ict is present-ed in I Kings, Chapter 12, of the Holy Bible. In this situation, Rehoboam, the young King of Israel, rejected the advice of his elders (men of his father’s gen-eration) and took the advice of younger men (his generation). This generational confl ict split the nation of Israel. More recently, lyrics of the song “In the Living Years” have portrayed movingly a major cause of generational confl ict as differ-ent worldviews, worldviews formed dur-

ing childhood that shape a generation’s adult values and expectations. Selected lyrics from this Song (see below) are especially pertinent to nursing. For ex-ample, consider the lyric line noting that talking in defense is like talking in a dif-ferent language which results in a bitter-ness that lasts.

The four generations of professional RNs in today’s workforce have very dif-ferent worldviews that are described below. The birth years for the different generations used in this article are the birth years used by Strauss and Howe (1991); the term professional is used to emphasize that registered nurses (RNs) are professionals; and the title descrip-tors for the four generations, Traditional, Baby Boomer, Generation X, and Net Generation Nurses, are based upon the author’s continued study of, and interac-tion with multi-generational nurses.

Dismayed Traditional Professional RNs (Birth Years pre 1944)Traditional colleagues were raised pri-marily in a Judeo-Christian culture that embraced transcendent moral truth and extolled the virtue of the Protestant Work Ethic. Thus, they value hard work and commitment to organizations and ‘bosses’ (Hu, Herrick, & Hodgin, 2004; Kupperschmidt, 2000; Strauss & Howe, 1991). Members of the Traditional Gen-eration entered nursing because they wanted to make a difference in peoples’ lives, and many viewed nursing as a ‘call-ing’ (Kupperschmidt, 2000). Although educated predominantly in hospital-

based diploma programs, Traditional generation RNs embrace the Nightin-gale Pledge and thus consider them-selves to be professionals. Strengths they bring to the workplace include their belief in hard work, doing a good job, and working together (Kupperschmidt, 2000; Strauss & Howe, 1991). They are

dismayed by, and strug-gling with, the perceived lack of professionalism among younger nurses as evidenced by younger nurses’ dress, behavior, and what they, as tradi-tional nurses, perceive to be vastly different work values. Traditional RNs are also discouraged by the age-related demean-ing remarks younger colleagues make about their fellow Traditional colleagues, as individu-als and as a generational cohort. Traditional RNs

are dismayed by the lack of attention to their ergonomic needs and perceived lack of respect for their cumulative wis-dom, wisdom they will take with them upon retirement, which may occur ear-lier than expected if their needs are not addressed (Cyr, 2005; Gerke, 2001; Let-vak, 2002).

Disappointed Baby Boomer Professional RNs (Birth Years 1944 -1960)Baby Boomers are credited with chal-lenging and changing many of the values held by the Traditional generation. They redefi ned family and childhood and em-braced values fostered by a personalized economy and spirit of free agency (Holtz, 1995; Russell, 1997). Their parents heeded Dr. Benjamin Spock’s advice and raised them to be independent, critical thinkers (Holtz, 1995). Boomer genera-tion RNs embrace the sense of profes-sionalism, viewing nursing as a career with their self-worth closely tied to their work ethic (Kupperschmidt, 2000). They are disappointed by the lack of available mid-level management positions; lack of attention to their ergonomic and life cycle needs; Generation X and Net Gen-eration colleagues’ age-related demean-ing remarks, and what they perceive as a

In the Living Years (Selected Lyrics)*

Every generation blames the one beforeWhen all their frustrations come beating on your door.I know that I’m a prisoner to all my father held so dear.I wish I could have told him in the living years.Crumpled bits of paper fi lled with imperfect thoughtsStilted conversations, I’m afraid that’s all we’ve got.You say you just don’t see it, he says it’s perfect senseYou just can’t get agreement in this perfect tense.We all talk a different language, talking in defenseSo we open up a quarrel between the presence and the pastWe only sacrifi ce the future; it’s the bitterness that lasts.

*Compact Disc cover, Mike and the Mechanics. Atlantic Recording Corporation 1988

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lack of professionalism by these younger colleagues (Ulrich, 2001). Baby Boomer generation nurses perceive they are car-rying the greatest share of the work in acute care settings (Santos & Cox, 2000); and they are experiencing high levels of role overload, role insuffi ciency, and in-terpersonal strain (Santos et al., 2003). Although they are disappointed that health care organizations are not evolv-ing into the kind of professional environ-ment in which they prefer to, and need to, work (Cyr, 2005), they maintain their strengths as process-oriented, team, and consensus builders and mentors (Kup-perschmidt, 2000; Ulrich et al., 2005).

Disillusioned Generation X Professional RNs (Birth Years 1961-1980)Generation X members are described as Baby Boomers’ children who inherited Boomers’ social debris: divorce and dual-career parents resulting in Latch Key Kid experiences (Holtz, 1995; Howe & Strauss, 1993). Generation X RNs were raised in an anti-child culture in which it was unpopular to be a child (Holtz, 1995; Howe & Strauss, 1993; Kupperschmidt, 1998). Many Generation X Nurses watched their parents, who had sacri-fi ced time with their children to advance their careers, receive pink slips in their later years (Holtz, 1995; Howe & Strauss, 1993). Zemke, Raines, and Filipczak (2000) have noted that employees’ fi rst job experiences signifi cantly impact their values and expectations of the work-place, including the nature of the work itself and relations with co-workers and managers. Many Generation X nurses fi rst work experiences occurred during a period of national recession and the re-organization and restructuring of health care organizations. Thus, they learned there is no such thing as job security. They have concluded that long term commitment to jobs and organizations, to paying dues, and to hierarchical rever-ence are to be avoided. Rather they be-lieve that attaining and maintaining mar-ketability is the key to personal success (Bradford & Raines, 1992; Holtz, 1995; Kupperschmidt, 1998; Tulgan 1995). Strengths Generation X colleagues bring to the workplace include their techno-competence, multi-tasking, and ability to work well alone (Holtz, 1995; Howe

& Strauss, 1993; Kupperschmidt, 1998). Generation X RNs are disillusioned by Traditional and Boomer colleagues’ per-ceived unwillingness to become techno-logically competent; frequent negative comments about them as individuals and about their generation (Tulgan 1995), and health care organizations that are not evolving into the kind of professional environments in which they expected to work (Bradford & Raines, 1992; Howe & Strauss, 1993; Swearingen & Liberman, 2004; Tulgan 1995).

Disengaging Net Generation Professional RNs (Birth Years 1981-2000)Net Generation colleagues were raised enmeshed in digital technology with computer games at nursery school. They were raised in the ‘Era of the Child’ when it was popular to be busy, protected children chauffeured by Soccer Moms (Howe & Strauss, 2000; Tapscott, 1998). Many have adopted the philosophy of moral relativism and consider truth as rel-ative. Net Generation RNs may perceive nursing as an occupation rather than a profession as literature about the current and impending nursing shortage consis-tently refers to available jobs in nursing. Strengths Net Generation professional RNs bring to the workplace comprise their techno-competence, openness to and expectation of virtual teams, and collective action (Howe & Strauss, 2000; Kupperschmidt, 2001; Tapscott, 1998). Net Generation nurses may be disengag-ing from nursing, however, because of Boomer and Generation X colleagues’ negative attitudes, media reports about negative conditions in acute care set-tings and nurses leaving nursing (Shaver & Lacey, 2003), and the lack of cutting-edge technology (Kupperschmidt, 2001). Thus, many of today’s health care orga-nizations may not be the kind of environ-ment in which the Net Generation RNs expect and desire to work.

The ChallengeMuch more could be and has been said about each generation. It is important, however, not to stereotype individu-als. Gerke (2001) has asserted that the health care work environment needs a huge overhaul to successfully use the strengths of professional nurses from

each of these highly diverse generations. Gerke (2001), and Duchscher and Cowin (2004), have stressed the importance of all staff learning about colleagues’ differences and dialoguing about how generationally determined values and ex-pectations are being played out in their organizations. Ulrich (2001) has empha-sized that colleagues’ workplace behav-iors legitimately derive from their gen-erational values, and has tied strengths and values together in a humorous ex-ample of how values infl uence how work gets done. Traditional colleagues value hard work and respect authority whereas Boomers value team work. Generation X Nurses value self-reliance and Net Gen-eration colleagues value achievement. In the workplace, a Traditional nurse might say, “Do it because I say so,” and a Boomer nurse might say, “Let’s get together and reach a consensus about how to do it.” The Generation X staff nurses might say they will do it them-selves; and Net Generation staff nurses might not care who does it as long as the work gets done. It is important to stress that professional RNs do not have to adopt colleagues’ generational values; but they do have to recognize, allow, and respect these different values. Lancast-er and Stillman (2002) referred to these differences as clash points whereas Ka-lisch and Begeny (2005) referred to the differences as idiosyncrasies. Lancaster and Stillman (2002) asserted that profes-sionals must be aware of and allow for these clash points and idiosyncrasies and respect colleagues’ generationally infl uenced strengths in order to enhance effective teamwork.

The Role of Respect in Multigenerational RelationshipsIt is the contention of this author that mu-tual respect could reduce multi-genera-tional confl ict among professional nurses in the workplace. Although no research studies were found which demonstrated a direct, positive correlation between generational lack of respect and work-place confl ict, related literature and an-ecdotal reports are available to support this contention as described below.

DeLellis (2000) stressed the important role of respect in professional relation-

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ships and developed an integrated typol-ogy addressing various aspects of the concept. In a later paper, DeLellis and Sauer (2004) contended the need to be respected is universal among human be-ings and is an essential element in bring-ing good into human life. They discussed respect as a function of individual behav-iors, values, and perceptions and built the case for respect as the ethical foun-dation for all employee relations. DeLel-lis and Sauer proposed that respectful communication has many faces: respect as active listening; respect as assertive speech; respect as avoidance of passive-aggressive communication; and respect during confl ict.

DeLellis (2004) studied respect in vari-ous work settings including health care settings and reported that 79% of those surveyed felt workplace respect was lacking in the United States to the extent that it was a serious problem. Regard-ing respect in hospitals, respondents believed that the quality of work life for hospital employees, including nurses, would improve if employees would care about and respect each other as much as they do their patients. Ulrich et al., (2005) conceptualize respect as a concept com-prised of four key elements: attention, deference, valuing, and appropriate con-duct. They expressed concern over the dearth of studies addressing staff nurses’ perceptions of respect. However, they acknowledged the considerable number of anecdotal comments about the lack of respect, adding that these comments are made because mutual respect is a vital aspect of effective working relation-ships among a multi-generational nurs-ing workforce.

Because of this author’s interest in gen-erational issues, colleagues have shared personal examples of disrespectful treat-ment. For example, Traditional and Boom-er colleagues have shared that younger colleagues disrespect them with remarks such as, “These old bitches take forever to learn technology.” Boomer colleagues have diffi culty understanding that from the perspective of moral relativism, be-cause someone (a Boomer colleague) fi nds the word ‘bitch’ offensive doesn’t mean a Net Generation colleague fi nds it

offensive, as evidenced by a Net Genera-tion colleague saying, regarding this word, “It is really no big deal.” Younger stu-dents complained that ‘older’ faculty are disrespectful when they make remarks such as, “Younger students just want the grade and don’t care about the content nor how they get the grade.” Addition-ally, Generation X nurses have offended Boomers by saying, “Boomers take for-ever to make decisions; they just want to process and process,” and Boomer col-leagues have reported younger nurses disrespect their need to carefully weigh all the facts and achieve consensus, by openly remarking, “Only old people take this long to make a decision!”

This author has also heard both under-graduate and graduate students, primar-ily Generation X and Net Generation students, describe how the different generations perceive respect and disre-spect. Both generations have described maintaining eye contact, paying atten-tion, and being polite (please, thank you, and using titles such as Mr. and Mrs.), as respectful behaviors; whereas interrupt-ing a speaker, gossiping, not paying at-tention, rolling one’s eyes when disagree-ing with a speaker, and not responding to telephone calls and e-mail messages were described as disrespectful by both of these generations.

If treating each other with mutual re-spect was a mandate from a regulatory agency, nursing would fi gure out an ef-fective way to meet the mandate. Yet, in essence, nursing does have an ethi-cal mandate clearly stated in the Ameri-can Nurses Association’s Code of Ethics (American Nurses Association [ANA], 2001). The Code of Ethics, Provision 1, states that nurses in all professional re-lationships practice with respect for the inherent dignity, worth, and uniqueness of all individuals

Carefronting Disrespect as StrategyThis section will begin with a description of Augsburger’s Model of Carefronting. Then Kupperschmidt’s adaptation of care-fronting for nursing will be presented.

Augsburger’s Model of CarefrontingFlowing from his years of experience as a family therapist, Augsburger (1973) coined the word carefronting to describe a model of communication. He asserted that carefronting, caring enough to con-front, is the key to effective relationships and the way to communicate with im-pact and respect in interpersonal relation-ships and work-related situations. Augs-burger has built the case for this model by noting that confl ict itself is natural and normal. It is the way people view, approach, and work through confl icted situations that infl uence their relation-ships. He asserted that silent withdrawal to disrespectful comments or behaviors is self-defeating because the relationship is only as good as the communication. He added that for carefronting to occur, both parties must be willing and able to state how they feel and what they value; they need to know that the other person is able and willing to work to understand them. Augsburger acknowledged that carefronting, i.e., making “I” statements and receiving the carefronting, requires courage. He asserted that failure to hon-estly and fully state one’s real feelings and viewpoints is not kindness; rather “it is a form of benevolent lying” (1973, p. 25). Augsburger explained that when a person is angered by disrespect, anger energies can become the creative force which enables the person to carefront the disrespectful behavior. Carefronting disrespectful behavior comprises nego-tiating differences in clear, respectful, truthful ways.

Augsburger (1981) has continued to develop carefronting by integrating the concept of forgiveness. The main thesis of this work is that when people forgive each other, they are both set free to meet genuinely and be fully present with each other. As Augsburger has explained, for-giveness lets go of anger, blaming, and avoidance; it comes to terms with the past and allows it to be truly past, thus allowing right and just relationships to evolve.

Kupperschmidt’s Adaptation of CarefrontingAlthough Augsburger’s model of care-fronting was published more than three decades ago, it remains relevant and

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pertinent today. In a 1994 publication, Kupperschmidt adapted carefronting to nursing, noting that carefronting means caring enough about one’s self and goals to confront in a caring, self-asserting, re-sponsible manner. She pointed out that carefronting considers nurses’ failure to confront as dishonest communication, a form of communication which negates the importance of relationships and goals. Kupperschmidt noted that carefronting is honest communication because in care-fronting one states what should be stat-ed (I want and deserve to be treated with respect) and what needs to be/should be stated (You and I have an ethical impera-tive to treat each other with respect); and it refuses to confuse the ‘should’ and the ‘need.’ In this article Kupperschmidt provided examples of ways to carefront, questions to be avoided, and strategies that allow colleagues to save face when being carefronted, stressing that care-fronting embodies forgiveness, a com-plex process of restoring caring and valu-ing, addressing the anger engendered by previous disrespectful behavior, and focusing on the here and now.

Professional nurses of all generations must acknowledge they are currently or have been angered and/or hurt by disrespectful treatment at the hands of another professional RN. Professional nurses must learn to carefront in order to become the caring professional nurses they purport to be. Provision 1.5 of the Code of Ethics (ANA, 2001), page 9, states that the professional nurse must treat colleagues with respect and main-tain a commitment to resolving confl icts with colleagues. In other words, each professional nurse has an ethical duty to resolve workplace confl icts. Becoming skilled in carefronting should assist indi-vidual nurses to embrace this ethical im-perative and more skillfully address and resolve confl icts.

Several scholars have identifi ed how carefronting can strengthen relationships among professional nurses. DeMarco (1998) asserted that caring enough to confront in the workplace is an ethical imperative for nurses. She shared fi nd-ings from two studies in which staff nurses reported they chose not to con-front nursing colleagues’ unacceptable behaviors because they were concerned

that confronting colleagues would dam-age the relationships and engender re-prisals, such as unwillingness to provide needed assistance and refusing to offer collegial help. In 2003 DeMarco and Rob-erts expressed their belief that if nurses will fi nd ways to support one another socially and care enough about each other to be direct and confront, profes-sional relationships among nurses will improve and respect will be heightened. Thus carefronting holds great promise as a strategy to help nurses represent-ing various generational cohorts come to understand each other more fully.

Recently Patterson, Grenny, McMillan, and Switzler (2005) endorsed crucial confrontation, a concept similar to care-fronting, in confl ict situations when the stakes are high. These authors stressed the need to start with the heart by asking the following three questions:

What do I want for me out of this relationship? What do I want for others out of this relationship? What do I want for the relationship?

They explained that professional nurses’ answer to these questions should be, “I want the ability to work together to pro-vide safe patient care in an environment based upon mutual respect.” Patterson et al. added that confrontation involves holding someone accountable by con-fronting them face-to-face, in situations involving disrespect.

Nursing Management’s Responsibility for a Respectful EnvironmentThe ANA Code of Ethics notes it is the responsibility of both individual staff nurses and nursing management to fa-cilitate an environment of respect. Pro-vision 6 of the Code notes that manag-ers and administrators are responsible for setting standards and managing the environment of care to assure that each employee is treated fairly and is able to practice in an environment conducive to the provision of quality health care con-sistent with the values of the profession (ANA, 2001). Adoption and enforcement of a zero tolerance policy for disrespect-ful behavior clearly communicates the expectation that “the nurse in all profes-sional relationships practices with…re-spect for the inherent dignity, worth and

•

•

•

uniqueness of every individual....” (ANA, 2001, p. 7).

Rowe and Sherlock (2005) conducted a study to identify the types and frequency of verbal abuse nurses experienced. Re-spondents reported that the most fre-quent source of abuse was other nurses. Rowe and Sherlock noted that this dis-respectful behavior increased job stress and decreased job satisfaction. They decried the fact that nurses have been taught to simply ‘grin and bear it,’ point-ing out that disrespect in the form of ver-bal abuse is quite costly to the individual nurse, the hospital, and the patients. They charged managers and administra-tors to adopt a zero tolerance policy for disrespectful behavior.

Managers can adapt cultural diversity educational offerings to address gen-erational diversity. Kupperschmidt (2000) described an array of generationally savvy management strategies based on the ACORN business model. Strategies within this acronym include: Accommo-dating employee difference; Creating workplace choices; Operating from a theoretically-sound, sophisticated man-agement style; Respecting employees’ competence and initiative; and Nourish-ing retention. Laschinger (2004), and Las-chinger and Finegan (2005), noted that when nurse managers provide access to information, support and resources, and opportunity for development, employees perceive they are respected.

In a short article directed toward manag-ers, Sanford (2005) presented a particu-larly poignant vignette. She described a toxic work environment that was al-lowed to continue for 14 years because professional nurses (staff and managers) refused to carefront the disrespectful behavior of an RN named Mary. Sanford asserted that allowing Mary’s behavior to continue provided a model and gave other nurses permission to be disre-spectful. She stressed the importance of managers, as well as staff nurses be-coming competent in confrontation skill, thereby setting the expectation for mu-tual respect.

SummaryIn summary, each generation of profes-sional nurses brings different genera-

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tionally infl uenced strengths and values to the workplace. It is a professional re-sponsibility to become knowledgeable regarding these differences in strengths and values, and to use them as a ful-crum to increase mutual respect (Kalisch & Begeny, 2005). Selected questions professional nurses might use to as-sist them to identify and effectively use colleagues’ generationally infl uenced strengths are included in the box. If all professional nurses assume their ethi-cal responsibility to treat others with respect and to carefront disrespectful behavior, their practice will be consistent with their professional values. Assum-ing this responsibility will create envi-ronments conducive to the provision of quality health care and workplaces hav-ing a minimum of multigenerational dis-respect and confl ict.

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• Ulrich, B. (2001). Successfully managing multi-gen-erational workforces. Seminars for Nurse Managers. 9, 147-153. • Ulrich, B., Buerhaus, P., Donelan, K. Norman, L., & Dittus, R. (2005). How RNs view the work environment. Journal of Nursing Administration, 35, 389-396. • Zemke, R., Raines, C., & Filipczak, B. (2000). Genera-tions at work. New York: American Management As-sociation.

Reprinted with permission, Nursing Economics, 2007.

Betty R. Kupperschmidt, EdD, RN, CNAA. E-mail: Betty-kupperschmidt@ouhsc.edu Dr. Kupperschmidt holds a Master’s de-gree in nursing and a Doctorate in Higher Education Administration. She has held a variety of leadership roles, including Clinical Director at a major medical cen-ter in Tulsa and Head of two Baccalau-reate Programs. She is completing her 14th year as Associate Professor at the University of Oklahoma - Tulsa, teach-ing the theory and clinical content of the Administration Pathway. A request from local nurse executives for help with leading and managing Generation X staff nurses led her to develop expertise in this area which is now recognized at state, national, and international levels.

Valuing and Using Nursing Colleagues’ Strengths:

Questions to AskQuestions to ask Traditional Colleagues to value and use their strengths:

Where does the Unit need to better manage resource consumption?Which tasks/jobs require close attention to time lines and details?How can we best use their traditional thinking?

Questions to ask Baby Boomer Colleagues to value and use their strengths:

Where can we most effectively use team members with strengths in mentoring?Which issues require consensus building?Which issues require a process orientation?

Questions to ask Generation X Colleagues to value and use their strengths:

Which jobs call for an entrepreneurial spirit?Where do we need a technologically skilled colleagues?How can trouble-shooting skills be more effectively valued and used?

Questions to ask Net Generation Colleagues to value and use their strengths:

How can we best value and use culturally sensitive viewpoints?How can we best incorporate new technology skills?How can colleagues become comfortable and competent within a virtual team?

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•

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• Hutton, S. (2006). Workplace incivility: State of the science. Journal of Nursing Administration, 36, 22-27. • Kalisch, B., & Begeny, S. (2005) Improving nursing unit teamwork. Journal of Nursing Administration, 35, 550-556. • Kupperschmidt, B. (1994). Carefronting: caring enough to confront. The Oklahoma Nurse, 7-10. • Kupperschmidt, B. (1998). Understanding Generation X employees. Journal of Nursing Administration, 28, 36-43. • Kupperschmidt, B. (2000). Multi-generation employ-ees: Strategies for effective management. Health Care Manager, 19, 65-76. • Kupperschmidt, B. (2001). Understanding Net Gen-eration employees. Journal of Nursing Administration, 31, 570 -574. • Kupperschmidt, B. (2004). Making a case for shared accountability. Journal of Nursing Administration, 34, 114-116. • Lancaster, L., & Stillman, D. (2002). When genera-tions collide. New York: HarperCollins. • Laschinger, H., (2004). Hospital nurses’ perceptions of respect and organizational justice. Journal of Nursing Administration, 34, 354-364. • Laschinger, H., & Finegan, J. (2005). Using empow-erment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economic$, 23, 6-13. • Letvak, S. (2002). Retaining the older nurse. Journal of Nursing Administration. 32, 387-392. • Manion, J. (2003). Joy at work? Journal of Nursing Administration, 33, 652-659. • Manion, J., & Bartholomew, K. (2004). Community in the workplace. Journal of Nursing Administration,34, 46-53. • Patterson, K., Grenny, J., McMillan, R., & Switzler,

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The Health Benefi ts of Fiber

W. Steven Pray, PhD, DPh

Fiber is one of the most misunderstood dietary components. Most people do not know how much fi ber should be ingest-ed daily and which foods and supple-ments offer the best choices for fi ber. Pharmacists can provide information and products to help educate and assist their patients in obtaining adequate in-take of fi ber.

Daily Fiber RecommendationsThe average American has a daily fi -ber intake of only 14 to 15 g. The daily recommendations for fi ber intake are higher than this, but they do vary slightly among population groups. For instance, the American Dietetic Association rec-ommends an intake of 20 to 35 g for adults, 25 g daily for girls ages 9 through 18 years and 31 to 38 g for boys ages 9 through 18.[1,2] The American Heart As-sociation recommends 25 to 30 g daily.[3] In 1994, the Institute for Cancer Preven-tion simplifi ed fi ber intake guidelines for Americans as the “age + 5” rule.[4] For children age 2 years and older, the rule is that children should consume a number of grams of fi ber each day that equals their age plus 5 additional grams. Thus, a 7-year-old should consume 12 g of fi ber daily for optimal health. This rule should be applied throughout adolescence until the person reaches age 20, when the adult guidelines should be used.

The Defi nition and Categories of FiberAt one time, fi ber was defi ned as any part of ingested plants that human en-zymatic actions cannot digest, such as cell wall components (e.g., waxes, lig-nin, pectin, celluloses).[5] However, dur-ing the 1970s, the meaning of “fi ber” gradually broadened to encompass and

embrace a physiological defi nition that has greater use for the medical profes-sion.[5,6] The expanded defi nition of fi -ber now includes ingested materials that are not components of plant cells (e.g., noncellulose plant storage saccharides such as gums, modifi ed celluloses, mu-cilages, oligosaccharides, and beta-glu-cans), although they are still resistant to degradation by human enzymes.[7]

Fibers are most usefully categorized for the medical professional on the ba-sis of their inability to dissolve in wa-ter.[8] Fibers that do dissolve in water (e.g., celluloses, pectin, other cell wall components, as well as gums and psyl-lium) form gels, some of which have one or more health benefi ts. Found in such foods as wheat, rice, maize, leafy vegetables, peas, beans, and rhubarb, soluble fi bers are able to sequester cho-lesterol and fats, facilitating their elimi-nation. Fibers that do not dissolve in water bind water in the distal colon.[9] Their sponge-like effect bulks stools and also binds various materials such as bile acids and carcinogens. Insoluble fi bers

are found in whole-grain cereals, breads, vegetables, and wheat bran.

Fiber’s Health Benefi tsNormalizing and Regulating Bowel FunctionThrough its OTC Review, the FDA evalu-ated fi ber products for use in regulating bowel function. Several plant-derived bulk-forming fi ber laxatives were found to be safe and effective--such as psyl-lium, malt soup extract, and bran. Bran and malt soup extract are not often mar-keted as nonprescription ingredients, but psyllium is widely available in a variety of dosage forms and options. The patient seeking a sugar-free psyllium product may use such products as Metamucil Sugar-Free Powder (3 g of dietary fi ber per teaspoonful) or Konsyl Original Pow-der (6 g of psyllium per teaspoonful). Several non-plant-derived ingredients also were found safe and effective as bulking agents, including methylcellu-lose (e.g., Citrucel) and polycarbophil (e.g., FiberCon Caplets, Phillips’ Fiber-Caps, Konsyl Fiber Tablets).A new fi ber ingredient is being market-ed in a product known as Fibersure. The

product contains inulin-type fructans, chicory-derived carbohydrate polymers characterized by fructosyl- fructose linkages.[10] The link-ages do not allow diges-tion in the upper diges-tive tract. Thus, they are fermented in the colon, increasing the mass and water content of stools. Inulin-type fructans are known as “functional foods” and thus have not been evaluated by the Source: US Pharmacist © 2006 Jobson Publishing

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FDA. Fiber supplementation is encour-aged by physicians and nurses to treat and prevent constipation.[11,12]

Little is known about hydrolyzed guar gum, as found in Benefi ber. The ingredi-ent has not been approved by the FDA as a nonprescription ingredient but is be-ing marketed as a dietary supplement. The National Academy of Sciences, in its Dietary Reference Intakes for Fiber, states that guar gum has “little effect on fecal bulk or laxation.”[13]

Weaning from StimulantsThe FDA considers seven days to be the safe time limit for use of laxatives with-out physician consultation. However, stimulant laxatives cause many patients to become habituated to them because of their nonphysiologic and drastic ac-tion; some patients might use laxatives for years once they become reliant on them. This practice can lead to changes in the colon that are carcinogenic and may result in death of colonic tissues lo-cated in the myenteric plexus. Patients should be urged to replace habitual use of stimulant laxatives with bulking agents. However, abrupt discontinuation in habitual laxative overusers may result in an inability to evacuate the bowels. The colon may not respond normally as a result of years of artifi cial stimulation. The patient may benefi t from a gradual withdrawal. In this method, the pharma-cist may recommend short-term stimu-lant use until the fi ber begins to exert its own effect. A combination of a stimulant and fi ber (e.g., SennaPrompt) might be useful for a 30-day period to boost co-lonic function and bridge the transition from stimulant addiction to natural facili-tation of bowel movements with fi ber. After that period, the goal should be per-manent discontinuation of stimulants in favor of fi ber intake.

Lowering CholesterolThe 1990 Nutrition Labeling and Educa-tion Act gave FDA authority to regulate health claims on food labels.[14] As a re-sult, manufacturers submitted research attempting to demonstrate the effect of various fi bers on health. Two fi bers have been proven safe and effective for the claims submitted. Beta-glucan soluble

fi ber from whole oats met the standard for reduction of risk from coronary heart disease.[15,16] Psyllium husk is also able to reduce the risk of coronary heart disease as it contains a soluble fi ber similar to beta-glucan.[17,18] Research-ers quantifi ed this outcome by deter-mining the effect of psyllium (5 g three times daily) in lowering cholesterol as an adjunct to 10 mg of simvastatin, as compared to doubling the dose of sim-vastatin to 20 mg.[19] They discovered that dietary supplementation with psyl-lium in patients taking 10 mg of simvas-tatin was as effective in lowering cho-lesterol as 20 mg of simvastatin alone. As a result of this research and FDA fi ndings, pharmacists can recommend ingesting psyllium supplements daily to consumers who wish to attain regular-ity of bowel movements while simulta-neously lowering their risk of coronary heart disease.

Weight ReductionThe popular media has given ample coverage to the epidemic of obesity in America. Almost 100 million Americans are either obese or overweight.[20] The fi gures climb each year, so that the toll of obesity will also continue to rise. Obesity has been linked to such morbid conditions as osteoarthritis in weight-bearing joints, type 2 diabetes, heart disease, cancer, and many other condi-tions. While hundreds of dietary supple-ments purported to be obesity cures are launched each year, the rising incidence of the condition attests to their ineffi ca-cy. The cure for obesity is actually quite simple. The overweight patient must eat less and exercise more, beginning im-mediately and continuing over the span of a lifetime.

Stomach distension (feeling full) signals a person to stop eating. It is in this area that fi ber can yield lasting benefi ts through several mechanisms. Fiber is a bulky food, more diffi cult to digest than fatty foods, fried foods, and candies. Once ingested, fi ber enhances satiety and prolongs satiation after a meal through distending the stomach and by prolong-ing retention of gastric contents.[21] The stomach is distended after a fi ber-con-taining meal because it promotes secre-

tion of saliva and of gastric acids, both of which distend the stomach. Ingestion of fi ber must be accompanied by water intake, which further serves to distend the stomach during a meal.[22] Prolong-ing gastric retention decreases the ab-sorption rate of nutrients, so that hunger does not return as rapidly.

Fiber also yields dietary benefi t through energy displacement or energy dilution. A person who ingests little fi ber in an average day usually has a diet of high-energy foods such as fats. However, the bulk that fi ber adds to the diet makes it impossible to eat the same quantity of high-energy foods. Research bears this out. If a patient adds 14 g of fi ber to the diet, energy intake will be reduced by approximately 10%.[22] Further, ob-servational studies of obese people and those who are thin confi rm that thin peo-ple ingest more fi ber and obese people ingest more high-fat foods.

Researchers explored the link between dietary fi ber/fat intake and excess weight in young and middle-aged adults.[21] They discovered that only 5% of the sample consumed adequate fi ber. Fur-ther, in women, consumption of a low-fi ber, high-fat diet was associated with the highest incidence of obesity when compared to those consuming a high-fi -ber, low-fat diet.

Prevention of Colon CancerFiber may help prevent colon cancer. The possible link stems from observational studies in the 1970s demonstrating that natives of Africa consuming high-fi ber diets had reduced risk of colorectal carci-noma.[23] Studies carried out to explore this link have been contradictory. Some seem to confi rm a protective effect, but others show little to no effect.[24] There is little risk to fi ber consumption. There-fore, with no clearly negative data about fi ber, it makes sense to increase fi ber intake just in case the positive studies did reveal an actual link. The patient will also experience the ancillary benefi ts of fi ber consumption, such as reduction in cholesterol (with psyllium), preven-tion of constipation, and reducing risk of hemorrhoids.

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Fiber and the Glycemic IndexFiber is especially benefi cial in patients with diabetes. Investigators adminis-tered 5.1 g of psyllium as a meal supple-ment to patients with type 2 diabetes, fi nding that it reduced the postprandial glucose and insulin concentrations.[25]

They concluded that psyllium was safe, well tolerated, and improved glycemic control.

References1. Eat fi ber for health. American Dietetic Association. Available at: www.webdietitians.org/Public/index_20411.cfm. Accessed April 11, 2006.

Source: US Pharmacist © 2006 Jobson Publishing

2. Help your children meet their fi ber needs. Available at: www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_4309_ENU_HTML.htm. Accessed April 11, 2006. 3. Fiber. American Heart Association. Available at: www.americanheart.org/presenter.jhtml?identifier=4574. Accessed April 11, 2006. 4. Marcason W. What is the “age+5” rule for fi ber? J Am Diet Assoc. 2005;105:301-302. 5. DeVries JW. On defi ning dietary fi bre. Proc Nutr Soc. 2003;62(1):37-43. 6. Prosky L. When is dietary fi ber considered a func-tional food? Biofactors. 2000;12(1-4):289-297. 7. Eastwood M, Kritchevsky D. Dietary fi ber: How did we get where we are? Annu Rev Nutr . 2005;25:1-8. 8. Slavin JL. Dietary fi ber and body weight. Nutrition. 2005;21:411-418. 9. James SL, Muir JG, Curtis SL, et al. Dietary fi bre: A roughage guide. Intern Med J. 2003;33(7):291-296. 10. Roberfroid MB. Introducing inulin-type fructans. Br J Nutr. 2005;93 Suppl 1:S13-S25. 11. Constipation. Am Fam Physician . 2005;71:539-540. 12. Mauk KL. Preventing constipation in older adults. Nursing. 2005;35:22-23. 13. Dietary reference intakes for energy, carbohydrate, fi ber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). The National Academies Press. Available at: www.nap.edu/books/0309085373/html/. Accessed April 11, 2006. 14. Fed Reg. 1996;61(3):296-337. 15. Fed Reg. 1996;62(15):3584-3601. 16. Fed Reg. 2003;68(144):44207-44209. 17. Fed Reg. 1997;62(99):28234-28245. 18. Fed Reg. 1998;63(32):8103-8121. 19. Moreyra AE, Wilson AC, Koraym A. Effect of com-bining psyllium fi ber with simvastatin in lowering cho-lesterol. Arch Intern Med. 2005;165:1161-1166. 20. Taylor E, Missik E, Hurley R, et al. Obesity treat-ment: Broadening our perspective. Am J Health Behav. 2004;28(3):242-249. 21. Howarth NC, Huang TT, Roberts SB, et al. Dietary fi ber and fat are associated with excess weight in young and middle-aged US adults. J Am Diet Assoc. 2005;105:1365-1372. 22. Barnard ND. Research on nutritional contributors to obesity. Available at: www.fda.gov/ohrms/dockets/dailys/03/Nov03/110703/03n-0338-ts00012.ppt. Ac-cessed April 11, 2006. 23. Franco A, Sikalidis AK, Solis Herruzo JA. Colorectal cancer: Infl uence of diet and lifestyle factors. Rev Esp Enferm Dig. 2005;97:432-448. 24. Anon. Dietary fi ber and colon cancer: The pen-dulum swings (again). Harv Mens Health Watch. 2005;10:1-5. 25. Ziai SA, Larijani B, Akhoondzadeh S, et al. Psyllium decreased serum glucose and glycosylated hemoglo-bin signifi cantly in diabetic outpatients. J Ethnopharma-col. 2005;102:202-207.

W. Steven Pray, PhD, DPh, Bernhardt Professor of Nonprescription Drugs and Devices, College of Pharmacy, South-western Oklahoma State University, Weatherford

Reprinted with permission, US Pharmacist, June 2007.

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Relationship of Antimicrobial Control Policies and Hospital and Infection Control Characteristics to Antimicrobial Resistance Rates

Elaine L. Larson, RN, PhD; Dave Quiros, MS; Tara Giblin, RN, MPH; Susan Lin, DrPH

IntroductionThe growing problem of antimicrobial re-sistance has been attributed in part to in-appropriate use of antibiotics and failure among healthcare providers to comply with infection control precautions.[1-3] Despite increased knowledge among healthcare providers about the spread of resistant pathogens and the publication of antimicrobial prescribing guidelines by the Healthcare Infection Control Practic-es Advisory Committee and professional organizations, antibiotics continue to be prescribed in excess or inappropriate-ly.[4,5] Most likely the rapid emergence of organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and van-comycin-resistant enterococci (VRE) also is associated with institution-wide fac-tors such as administrative enforcement of recommendations among staff.[1]

Because providing care to patients infect-ed by antimicrobial-resistant organisms contributes to the continued increase in healthcare expenditures, administra-tive strategies are being implemented to reduce resistance in acute and long-term care facilities. These strategies in-clude automatic stop orders for use of antibiotics, required pharmacy or infec-tious disease consultations for prescrip-tion of certain antibiotics, surveillance of pathogen-specifi c resistance rates, and the development of in-house antimicro-bial control policies and guidelines.[1,5-7] In a recent study[7] of 120 Canadian hospitals, among institutions in which surveillance for antimicrobial-resistant organisms was conducted and health-care-associated infection rates were re-ported, rates of MRSA were signifi cantly lower than in institutions without such surveillance and reporting.

Nevertheless, many questions about the relationship between institutional policies and practices and antimicrobial resistance remain. For example, the ex-tent to which hospitals have designed specifi c methods for tracking resistance and limiting prescribing of antibiotics is unknown. Furthermore, hand hygiene is the mainstay of preventing the trans-mission of antimicrobial-resistant patho-gens, yet it is unclear whether staff at-titudes toward and practices of hand hygiene are associated with rates of an-timicrobial resistance.[8] The purposes of this study were to determine the ex-tent to which hospital infection control programs include surveillance of antimi-crobial-resistant pathogens and to cor-relate rates of antimicrobial resistance with characteristics of infection control policies and programs and attitudes to-ward and practices of healthcare work-ers regarding hand hygiene.

MethodsSampling ProceduresThis project was a component of a larger study, Impact of Hand Hygiene Guide-line on Infections and Costs (National Institute of Nursing Research). The par-ticipants in the study were recruited from among hospitals that were mem-bers of the National Nosocomial Infec-tion Surveillance (NNIS) System, a vol-untary reporting network of more than 300 acute care hospitals representing nearly every state in the United States and coordinated by the Centers for Dis-ease Control and Prevention (CDC).[9] The target sample size of hospitals (n = 36) was based on the number of hos-pitals needed to detect a difference in infection rates among those implement-ing or not implementing the CDC hand

hygiene guideline.[8] To recruit hospitals for the larger study, a letter describing the study was sent by mail and e-mail from CDC to NNIS hospitals. Interested individuals were asked to contact the in-vestigators and the individuals’ eligibility then was determined.

Eligibility criteria for participation in the study included being an NNIS hospital or using NNIS methods and defi nitions since at least 1999, having reported data by using the intensive care unit (ICU) surveillance component since at least 2000 (to ensure that suffi cient, stan-dardized data were available), and not using alcohol-based products for hand hygiene before June 2002. All hospitals participating in the larger study were later invited by e-mail to take part in this supplemental component to assess an-timicrobial control policies and rates of antimicrobial resistance.

InstrumentsFour instruments were used for the study. The Implementation Assessment Survey was used to measure implemen-tation and diffusion of the CDC hand hygiene guideline at the hospital sys-tems level. This instrument consisted of 3 parts: (1) introduction of the guide-line within the hospital (eg, where cop-ies were kept, the extent to which the guideline had been discussed and dis-seminated), (2) presence of the recom-mended products on clinical units in the year before and after publication of the guideline, and (3) written institutional policies and procedures regarding hand hygiene. In addition, information about infection control staff and the hospital was recorded (eg, education and years of experience of staff, number of hos-

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pital beds, geographic location of the hospital).

The survey included 12 items to assess the implementation of recommendations from the guideline, such as whether spe-cial sessions were conducted to edu-cate staff about the CDC guideline and whether a formalized plan was in place to monitor compliance with hand hy-giene. Possible scores on the Implemen-tation Assessment Survey ranged from 0 to 12; higher scores indicate greater hospital-wide administrative efforts to implement the guideline. Before fi nal use in this study, the survey form was pilot tested among the infection control staff in 5 hospitals in New York City for content validity and clarity; interrater reli-ability was 0.92.

The Hand Hygiene Observation Instru-ment was used for direct observations of hand hygiene behavior. The tool lists the 8 indications for hand hygiene from the CDC guideline:

before direct contact with a patient; before donning sterile gloves when inserting a central venous catheter; before inserting invasive devices; after touching a patient’s intact skin; after touching body fl uids, wounds, or nonintact skin; before moving from a contaminated body site to a clean body site in the same patient; after contact with inanimate objects in the vicinity of a patient; and after removing gloves.

While directly observing a care provider, the observer checked when one of the indications occurred, then whether hand hygiene also occurred, either with soap and water or with an alcohol-based prod-uct. Based on these observations, an overall hand hygiene rate (number of hand hygiene episodes per number of indications) and the proportion of hand hygiene episodes that occurred with ei-ther soap and water or with alcohol were calculated. Before the instrument was used, it was pilot tested by 4 research assistants who independently conduct-ed observations in 3 different ICUs; the interrater agreement was 0.98.

1.2.

3.4.5.

6.

7.

8.

The Attitudes Regarding Practice Guide-lines survey was adapted from instru-ments originally developed by Cabana and colleagues.[10-12] Preliminary psy-chometric testing of the tool has been described.[13] The tool uses a 6-point Likert scale and has 2 sections: section 1 included 18 attitudinal statements about practice guidelines in general; section 2 included 18 parallel statements spe-cifi cally about the CDC hand hygiene guideline. Possible scores ranged from 0 to 180; higher scores indicate fewer perceived barriers to use of clinical prac-tice guidelines in general and the CDC hand hygiene guideline specifi cally. Ad-ditionally, respondents were asked to (1) name the most important factors that would either facilitate or prevent the re-spondents’ use of the guideline and (2) self-report the proportion of time when they used an alcohol-based hand hygiene product.

To assess antimicrobial control policies, an 8-item survey was completed by the director of infection control in each hos-pital. The fi rst item determined whether the hospital had a policy for restricting use of antibiotics. For those hospitals with a policy, the remaining items were used to determine which antibiotics were restricted, justifi cation requirements for prescribing antibiotics, requirements for approval by the infectious disease de-partment before antibiotics could be pre-scribed, implementation of stop orders for use of antibiotics, suggestions for use of alternative drugs, recommended route of antibiotic administration, and whether the policy indicated that the hospital had a pharmacy and therapeu-tics committee.

ProcedureThe study was reviewed and approved by the institutional review board of each participating hospital. During a 2-day site visit to each hospital, the study project director collected data from the direc-tor of the infection control department, including the Implementation Assess-ment Survey; written hand hygiene poli-cies and procedures; documents on staff education, infection control policies and procedures, product usage, and multidis-ciplinary meetings on hand hygiene; and

rates of healthcare-associated infections within the ICUs studied.

During the site visit, the project director also made rounds in one or more ICUs in each hospital to record the proportion of rooms for patients’ care and general areas in which alcohol products were available, to directly observe staff hand hygiene, and to administer the Attitudes Regarding Practice Guidelines Survey to ICU staff working during that shift (ie, physicians, nurses, and any ancillary di-rect care staff such as respiratory thera-pists). From 2 to 5 hours of observation during 1 to 2 days were completed until at least 24 hand hygiene episodes were recorded. To ensure that the practices of a single staff member did not bias the re-sults, each staff member was observed a maximum of 3 times.

For infection control staff who also agreed to provide data on antimicrobial resistance, participants provided copies of their antimicrobial control policies and procedures in addition to hospital-wide rates of 3 organisms, if available: MRSA, VRE, and ceftazidime-resistant Klebsiella pneumoniae. Antimicrobial resistance data were obtained for the most recent 12 months. The time between imple-mentation of the CDC guideline and cal-culation of rates of resistant strains was 2 to 3 years for each hospital.

Data AnalysisContent analysis was performed to de-scribe each hospital’s antimicrobial con-trol policies. Rates of MRSA, VRE, and ceftazidime-resistant K pneumoniae were obtained from each hospital. Rates were calculated as the number of iso-lates that were resistant divided by the total number of isolates of each species (eg, number of isolates of MRSA/total number of isolates of S aureus). The me-dian rate of resistance was calculated across all participating hospitals. For the purposes of the analyses, rates of each of the 3 resistant organisms were dichot-omized as high or low, defi ned as at or greater than the median (high resistance rates) or less than the median (low resis-tance rates), respectively, for each hos-pital. Bivariate analyses with 2 or t tests were then used to examine correlations

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between institutional characteristics and high or low rates of MRSA, VRE, or cef-tazidime-resistant K pneumoniae. Vari-ables examined in these analyses includ-ed hospital characteristics (affi liation with an academic health center, geographic region, number of beds), characteris-tics of the infection control department (number of years staff had worked in in-fection control, number and professional disciplines of infection control staff, edu-cational preparation), presence of antibi-otic-restriction policies, scores from the Attitudes Regarding Practice Guidelines survey and Implementation Assessment Survey, and observed rates of hand hy-giene. For variables signifi cantly associ-ated with resistance rates in the bivari-ate analyses (P < .05), logistic regression models were fi t to examine the indepen-dent effects of each variable.

ResultsA total of 33 infection control directors provided data on antibiotic policies and resistance rates. Characteristics of the infection control directors and their hos-pitals are described in Table 1 . Of the 33 hospitals, 10 (30.3%) had an antimicro-bial restriction policy. Six restricted only vancomycin use, whereas 4 restricted use of vancomycin as well as use of other antibiotics, including linezolid, cefo-taxime, aztreonam, ticarcillin/clavulanate, and amphotericin B. Of the 10 policies, 7 required that the prescribing clinician provide justifi cation when ordering a restricted antibiotic and 7 required that an infectious disease physician approve the order before it was fi lled by the phar-macy. Six of the policies specifi ed auto-matic stop orders for restricted antibiot-ics, usually 72 hours for vancomycin, and 6 specifi ed a route of administration (eg, oral, intravenous). Only 3 of the policies suggested alternative drugs to common-ly prescribed antibiotics. Half of the poli-cies noted the existence of a pharmacy and therapeutics committee.

Rates of MRSA, VRE, and ceftazidime-resistant K pneumoniae were 52.5%, 18.2%, and 16.0%, respectively ( Table 2 ). Susceptibility patterns from 9 hospi-tals (27.3%) indicated low rates of resis-tance (ie, <median resistance rates for all hospitals) for all 3 organisms tested. A

total of 9 hospitals (27.3%) had high rates for 1 of the 3 organ-isms, 9 (27.3%) had high rates for 2 of the 3 organisms, and 6 (18.2%) had high rates for all 3 organisms.

In bivariate analyses, hospitals that scored high (11 or 12) on the Implementation Assess-ment Survey had signifi cantly lower rates of MRSA than did hospitals with lower implemen-tation scores (P < .05). Four variables correlated with VRE rates in bivariate analyses: geo-graphic region of the hospital, score on the Implementation Assessment Survey, hand hy-giene observation score, and number of active beds. Hospi-tals located in the western re-gion of the United States had signifi cantly lower rates of VRE than did hospitals located in the eastern region (P = .049). Hos-pitals that scored high on the Implementation Assessment Survey also had signifi cantly lower rates of VRE (P < .001) than did hospitals with lower scores. Hospitals with observed hand hygiene compliance rates of 59.0% or greater had signifi cantly lower rates of VRE than did hospitals with lower compliance rates (P = .05), and hospi-tals with 471 or more active beds had signifi cantly higher levels of VRE than did hospitals with fewer beds (P = .01). Only geographic location of the hospital was signifi cantly correlated with rates of resistant K pneumoniae. Hospitals in the eastern region of the United States had signifi cantly higher rates than did hos-pitals in the western region (P = .003). Hospitals in which the proportion of hand

hygiene with an alcohol product was higher and in which the infection control department routinely monitored hand hy-giene had lower rates of resistance for all 3 organisms, although results were not signifi cant ( Table 3 and Table 4 ).

In the logistic regression analysis, imple-mentation score was the only signifi cant predictor of higher rates of MRSA and VRE. That is, compared with hospitals with low implementation scores, hospi-tals with high implementation scores had signifi cantly lower rates of MRSA and VRE ( Table 5 ). None of these variables were associated with rates of resistance in K pneumoniae.

Table 1. Characteristics of Hospitals and Infection Control Departments (N = 33)

Table 2. Number of Isolates Tested and Mean Rates of Methicillin-resistant Staphy-lococcus Aureus, Vancomycin-resistant Enterococci, and Ceftazidime-resistant Klebsiella Pneumoniae (N = 33 Hospitals)

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DiscussionThe rates of resistance reported by our study participants were lower than, but consistent with, rates reported in the latest published NNIS summary of 2004: for MRSA, 52.5% in our study and 59.5% in the NNIS; for VRE, 18.2% and 28.5% respectively; and for K pneu-moniae resistant to ceftazidime, 16.0% and 20.6% respectively.[14] Strategies that have been used to minimize the emergence of antimicrobial resistance in healthcare settings have included admis-sion screening and isolation of carriers, antibiotic restriction policies, education of clinicians, feedback, implementation of guidelines, and vaccination.[15] The admission screening and isolation of carriers, referred to as the “search-and-destroy” approach, has become routine in several European countries, including the Netherlands, Denmark, and Ger-many, and has been recommended by some in the United States.[16-20] Low rates of healthcare-associated MRSA ac-quisition and reduced costs have been attributed to this strategy.[18,20,21]

In a systematic review of 43 studies de-signed to assess the effectiveness of strategies to reduce resistance rates, Wilton et al[15] identifi ed the need to develop and evaluate “macro” strate-gies such as the search-and-destroy approach that involve entire systems of care or institutional management. In our study, we attempted to examine the impact of some of these macro factors (characteristics of hospitals and infection control departments) and staff attitudes toward practice guidelines and hand hy-giene behavior on rates of 3 antibiotic-resistant organisms.

Impact of Antibiotic Use PoliciesOne of the fundamental strategies to reduce antimicrobial resistance has been the implementation of policies for antibiotic use and prescribing restric-tions.[22] Several studies have indicated signifi cant reductions in inappropriate antibiotic prescribing[23] and in rates of multi resistant infections[24-28] associ-ated with such policies, but these stud-ies to date have generally been small, restricted to a single institution or even a single unit within an institution. In a

Table 3. Association Between Hospital Characteristics and Rates of Methicillin-resistant Staphylococcus Aureus, Vancomycin-resistant Enterococci, and Ceftazi-dime-Resistant Klebsiella Pneumoniae, Bivariate Analysis, X2 Analysis

Table 4. Association Between Hospital Characteristics and Rates of Methicillin-resistant Staphylococcus Aureus, Vancomycin-resistant Enterococci, and Ceftazi-dime-Resistant Klebsiella Pneumoniae, Bivariate Analysis, t Test

Table 5. Predictors of Rates of Methicillin-resistant Staphylococcus Aureus and Vancomycin-Resistant Enterococci, Logistic Regression

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review of evidence of a relationship be-tween antibiotic policies and control of resistance, Gould[29] noted that much of the evidence did not meet current standards for evidence-based practice, and others[30,31] have confi rmed that additional research is needed to estab-lish a causal relationship between anti-biotic use policies and changes in rates of resistance.

In an Italian study[32] conducted in 2000, only 9.6% of hospitals reported having a surveillance system for anti-microbial-resistant organisms, and 18% had an antibiotic policy committee that met at least yearly. The authors[32] con-cluded that intensive efforts are needed to better understand how to adopt uni-form policies to reduce antimicrobial resistance. In our study, fewer than one third (10/33) of hospitals surveyed re-ported having antibiotic control policies. This low rate is surprising because the participants were members of the NNIS network of hospitals, which might be more likely than nonparticipating hos-pitals to be early adapters and/or cur-rent in their policies and practices. This rate is also lower than that reported in a recent survey[33] of 494 US hospital laboratories in which 60% reported that they had implemented antimicrobial use guidelines and 53% reported that they provided suffi cient resources to prevent resistance. Possibly the infection control directors in the hospitals we surveyed were unaware of antibiotic control poli-cies in the hospital, but that explanation seems unlikely.

Even among those hospitals that have antibiotic control policies, the extent to which the policies have been enforced is unknown. Implementation of antibiotic control policies may be an important po-tential source of intervention to reduce resistance. In our sample of hospitals we found no correlation between having standardized, written antibiotic steward-ship policies and hospital-wide rates of MRSA, VRE, or ceftazidime resistant K pneumoniae; however, we had no data on the extent to which these policies were actually implemented. A similar lack of such data occurred in the large national survey by Diekema et al.[33]

Hence, these studies cannot be used to determine whether such policies might have an impact if the policies were actu-ally practiced.

Impact of Hospital-wide Indicators of Guide-line ImplementationAlthough the data used to assess the level of guideline implementation were obtained in large part from an interview with the directors of infection control, we verifi ed facts by reviewing minutes, edu-cational records, and administrative data and by direct observation on units (eg, to confi rm the presence of products). Hence, we believe the implementation score was an accurate refl ection of sys-tems-level practices. The implementa-tion score most likely is a surrogate for the extent to which the infection control program in general is current and effec-tive and/or the level of administrative support for the implementation of new guidelines.

Our fi ndings indicate a strong relationship between this implementation score and rates of 2 of the 3 resistant organisms we examined. For example, although number of hospital beds, geographic lo-cation in the eastern United States, and lower rates of staff hand hygiene, along with the implementation score, were signifi cantly associated with higher rates of VRE in bivariate analyses, the only sig-nifi cant predictor of higher VRE rates in the logistic regression analysis was the extent to which the hospital had imple-mented the CDC guideline.

The fi nding that hospitals with higher implementation scores also had lower rates of MRSA and VRE is consistent with the hypothesis that administrative and organizational factors such as im-proved infection prevention and control programs play an important role in pre-venting the spread of resistance. In the classic Study of the Effi cacy of Noso-comial Infection Control conducted in the 1970s, infection prevention strate-gies implemented in a systematic way were associated with reduced rates of infection.[34] Our study provides evi-dence that these same strategies may also have a signifi cant impact on rates of antibiotic resistance. This interpreta-

tion is consistent with the results of a survey[35] of 172 acute care Canadian hospitals in which defi cits in various components of infection control pro-grams were identifi ed. The authors[35] suggested that greater investment in resources to support these programs might be associated with reduced rates of infection and resistance. Smith et al[36] developed conceptual mathemati-cal models that indicated that regional coordination and planning across hos-pitals might be an essential element in ultimately preventing interinstitutional epidemics of antimicrobial resistance.

For K pneumoniae, only geographic lo-cation of the hospital (eastern half of the United States) was signifi cantly as-sociated with higher rates of resistance. Although we found no association be-tween any of the other factors we exam-ined and rates of resistance, Patterson et al[37] reported a signifi cant reduction in rates of resistance among Klebsiella isolates after an intervention that includ-ed emphasis on contact precautions and education about use of antibiotics.

Impact of Staff Attitudes and Ob-served Hand Hygiene PracticesWe found no association between staff self-reported knowledge of or attitudes toward practice guidelines or hand hy-giene and rates of antibiotic resistance. The lack of such a relationship is not sur-prising because little evidence exists for a link between self-reported attitudes and actual hand hygiene behavior.[38-41] For that reason, most likely little reason exists to obtain self-report data from staff except perhaps to measure changes in knowledge and attitudes af-ter a specifi c intervention.

The lack of a relationship between ob-served hand hygiene rates and rates of resistance may be related to changes in behavior associated with the Hawthorne effect; because staff members were aware that their hand hygiene behavior was being observed by an outside ob-server, the observations most likely were not representative of usual practice. The availability of valid measures of hand hy-giene continues to be a major deterrent to studies to examine the relationship

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between hand hygiene and patients’ out-comes such as rates of multi resistant infections. Even though self-reported at-titudes and practices may have little cor-relation with outcomes, evidence sug-gests that low nurse staffi ng and other organizational factors such as high nurse turnover rates do have an effect on rates of infection. Investigators[42-44] have speculated that one intervening factor could be that inadequate numbers of trained staff result in inadequate infec-tion control practices. No data are avail-able on a potential relationship between such factors and resistance rates.

LimitationsThis study had several limitations. Epi-sodes of hand hygiene were directly observed by a trained researcher, a situ-ation that most likely resulted in behav-ior change among staff members who knew that they were being observed. Furthermore, the observations took place over a short time: 1 or 2 days. Hence, the hand hygiene rates probably are biased. Of particular concern is the fact that the rates were so low even though most staff members were aware their hand hygiene practices were being observed.

Our sample of 33 hospitals was not large, even though it was geographi-cally dispersed. Although we noted a consistent trend toward reduced rates of resistance among hospitals that had processes to routinely monitor hand hygiene and hospitals with higher rates of use of an alcohol hand product, the lack of statistical signifi cance in these relationships may have been due to in-suffi cient statistical power. Because the NNIS system is voluntary, it is not rep-resentative of all US hospitals. Still, an advantage of NNIS hospitals is that their surveillance systems and defi nitions are comparable and conform to rigorous standards. Resistance data were ob-tained from the microbiology laboratory at each participating hospital and did not include a single isolate per patient per admission. Therefore, multiple cultures from the same patient might have been included in both the numerator and de-nominator of these rates.

Two inconsistent fi ndings in this study warrant discussion. First, if a relation-ship exists between implementation score and resistance, one would expect to see the relationship consistently for all 3 organisms studied rather than 2 of the 3 only. A possible reason for the lack of a signifi cant association between imple-mentation score and rates of resistant K pneumoniae is that fewer than half the number of isolates of this species were available for analysis, hence the statisti-cal power was considerably less. In ad-dition, compared with resistant K pneu-moniae, MRSA and VRE may be more sensitive indicators of systems-level factors such as staffi ng, because MRSA and VRE are more likely to be transmit-ted on the hands of health-care person-nel.

The second inconsistent fi nding is that observed rates of hand hygiene were consistently low across all hospitals, regardless of the systems-level imple-mentation score. Only for VRE did hos-pitals with low rates of resistance have both signifi cantly higher implementation scores and signifi cantly higher hand hy-giene rates. (Even then, however, the differences in rates of observed hand hygiene probably were not clinically im-portant, because they were only 50% and 59% in hospitals with high and low levels of resistance, respectively.) Al-though one would hope that improved implementation of a guideline would be directly associated with improved prac-tice, the implementation score was not designed to measure changes in prac-tice. Instead, it was a marker of orga-nizational-level characteristics that may have had an impact on other important predictors such as staffi ng and adminis-trative commitment.

On the one hand, these fi ndings are discouraging because making adminis-trative changes and providing materials needed to implement a guideline are perhaps necessary but clearly are not suffi cient to effect any discernible prac-tice change at the staff level, at least in the short term. On the other hand, these data suggest that organizational factors in addition to individual staff practices may have a direct impact on important

clinical outcomes such as antibiotic re-sistance. These intriguing fi ndings war-rant further study.

Summary and RecommendationsThis study was one of the fi rst attempts to correlate organizational characteris-tics with antimicrobial resistance rates across a number of hospitals. Hospi-tals that had antibiotic use policies did not have signifi cantly lower rates of re-sistance. Clearly, simply having such a written policy is insuffi cient to have an impact without administrative measures to implement the policy. The extent to which hospitals had implemented the CDC hand hygiene guideline was the only factor signifi cantly associated with lower rates of MRSA and VRE. We con-clude that prevention efforts adminis-tered through system-wide infection control programs may be an important contributor to minimizing rates of antimi-crobial resistance.

Journal Club Article Discussion Points: by Ruth KleinpellIn a journal club, research articles are re-viewed and critiqued. General and spe-cifi c questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the va-lidity of the conclusions, and the implica-tions of the article for clinical practice.When critically appraising this issue’s journal club article, “Relationship of An-timicrobial Control Policies and Hospital and Infection Control Characteristics to Antimicrobial Resistance Rates,” consider the questions and discussion points listed below. To begin a discus-sion thread about the article online, visit http://ajcc.aacnjournals.org/, read the ar-ticle in either its full-text or .pdf format, and click on “Respond to This Article” (the link appears in bright blue in a list on the right-hand side of the page).

Study SynopsisThe purpose of this study was to exam-ine the infection control practices of hos-pitals; specifi cally, how infection control programs monitored resistance, provid-ers’ attitudes and practices, and imple-mentation of the Centers for Disease Control and Prevention (CDC) hand hy-

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giene guidelines. Thirty-three hospitals were assessed using on-site surveys of intensive care unit (ICU) staff and inter-views with infection control directors. Data were collected on antimicrobial con-trol policies, resistance infection rates during the previous 12 months, ICU staff attitudes toward practice guidelines, and through direct observations of staff hand hygiene. Of the 33 hospitals, only 10 had an antibiotic control policy. Rates of an-timicrobial resistance were lower but consistent with national rates, at 52.5% for methicillin-resistant Staphylococcus aureus (MRSA), 18.2% for vancomycin-resistant enterococci (VRE), and 16.0% for ceftazidime-resistant Klebsiella pneumonia rates. In analyzing factors associated with rates of antimicrobial resistance, higher scores on measures of system-level efforts to implement the CDC guidelines were associated with lower rates of MRSA and VRE.A. Description of the Study

What was the purpose of the re-search? Why is the problem signifi cant for those working in critical and high acuity care environments?

B. Literature EvaluationWhat strategies have been identi-fi ed as benefi cial for reducing anti-microbial resistance in previous re-search on antimicrobial resistance?

C. SampleHow were hospitals selected for study participation?

D. Methods and DesignHow were the data collected?

E. ResultsWhat were the fi ndings of the re-search? What was the impact of staff atti-tudes and observed hand hygiene practices?

F. Clinical Signifi canceWhat are implications of the study for clinical practice?

Information From the Authors: Elaine Larson, RN, PhD, lead author of this jour-nal club article, provided additional infor-mation about the study. She shares that the study was conducted by a research team that was formed to study the topic of antimicrobial resistance as part of an offi cial center funded by the National In-

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stitute of Nursing Research and the Na-tional Center for Research Resources. She notes: “We are very interested in antimicrobial resistance because it has become such a global problem and be-cause I am the principal investigator on the Center for Interdisciplinary Research on Antimicrobial Resistance (http://www.cumc.columbia.edu/dept/nursing/CIRAR/). It is clear that many of the ac-tions being taken to reduce resistance are not working. We believe that part of the reason is because a more ‘systems’ approach rather than focusing solely on individual providers may be needed.”

Dr Larson further relates that the hospi-tals that participated in the study were open to sharing their data on antimicro-bial resistance rates and antimicrobial control policies. “Since the data are pre-sented without identifi ers and since the infection control staff members are as eager and committed as we are to deal effectively with resistance,” she states, “we did not encounter any resistance. However, keep in mind that each hospi-tal volunteered to be in the study–those that were resistant would simply not have volunteered.” She adds that the most surprising fi nding of the study re-lated to the number of hospitals with formal policies guiding antibiotic pre-scribing. “I was completely surprised to learn that so few institutions had formal antibiotic prescribing or restriction poli-cies,” she notes. “I would have guessed that most would.”

Dr Larson indicates that the research team is planning additional studies re-lated to infection prevention. “We have just submitted a large project grant to the National Institutes of Health that in-cludes 9 related studies, but we won’t know until August 2007 whether we re-ceive funding. In the meantime, through our center we will continue to work with a large interdisciplinary team to identify important research questions related to resistance.”

Implications for PracticeAccording to the study results, hospitals that had implemented the CDC hand hygiene guidelines had lower rates of MRSA and VRE infections. The results

highlight the impact of the basics of in-fection prevention with hand hygiene measures. Dr Larson outlines several implications of the study results for readers of the American Journal of Criti-cal Care. “It is likely to be impossible to stem the increasing tide of antibiotic resistance without system-wide, mul-tidisciplinary collaboration and without strong administrative support and com-mitment,” she points out. “Although in-fection control departments have been given primary ‘responsibility’ for control-ling and preeeventing infections, they can only put processes and structures in place–they cannot, on their own, change practice.”

References1. Boyce JM. Consequences of inaction: importance of infection control practices. Clin Infect Dis. 2001;33(sup-pl 3):S133-S137 2. Kollef MH, Micek ST. Strategies to prevent antimicro-bial resistance in the intensive care unit. Crit Care Med. 2005;33:1845-1853 3. Trampuz A, Widmer AF. Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo Clin Proc. 2004;79:109-116 4. Hospital Infection Control Practices Advisory Com-mittee (HICPAC). Recommendations for preventing the spread of vancomycin resistance [published correction appears in Infect Control Hosp Epidemiol. 1995;16:498]. Infect Control Hosp Epidemiol. 1995;16:105-113 5. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis. 1997; 25:584-599 6. Critchley IA, Karlowsky JA. Optimal use of antibiotic resistance surveillance systems. Clin Microbiol Infect. 2004;10:502-511 7. Zoutman DE, Ford BD. The relationship between hospital infection surveillance and control activities and antibiotic-resistant pathogen rates. Am J Infect Control. 2005;33:1-5 8. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICCCPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiol-ogy of America/Association for Professionals in Infec-tion Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002; 51(RR-16):1-45 9. Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the CDC experience. Jt Comm J Qual Improv. 1996;22:457-467 10. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A frame-work for improvement. JAMA. 1999; 282:1458-1465 11. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000;154:685-693

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12. Cabana MD, Rand CS, Becher OJ, Rubin HR. Rea-sons for pediatrician nonadherence to asthma guide-lines. Arch Pediatr Adolesc Med. 2001;155:10571062 13. Larson E. A tool to assess barriers to adher-ence to hand hygiene guideline. Am J Infect Control. 2004;32:48-51 14. National Nosocomial Infections Surveillance Sys-tem. National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485 15. Wilton P, Smith R, Coast J, Millar M. Strategies to contain the emergence of antimicrobial resistance: a systematic review of effectiveness and cost-effective-ness. J Health Serv Res Policy. 2002;7:111-117 16. Farr BM. Prevention and control of methicillin-resis-tant Staphylococcus aureus infections. Curr Opin Infect Dis. 2004;17:317-322 17. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol. 2003;24:362-386 18. Vriens M, Blok H, Fluit A, Troelstra A, Van Der Werken C, Verhoef J. Costs associated with a strict policy to eradicate methicillin-resistant Staphylococcus aureus in a Dutch university medical center: a 10-year survey. Eur J Clin Microbiol Infect Dis. 2002;21:782-786 19. Wernitz MH, Swidsinski S, Weist K, et al. Effec-tiveness of a hospital-wide selective screening pro-gramme for methicillin-resistant Staphylococcus aureus (MRSA) carriers at hospital admission to prevent hos-pital-acquired MRSA infections. Clin Microbiol Infect. 2005;11:457-465 20. Wertheim HF, Vos MC, Boelens HA, et al. Low prevalence of methicillin-resistant Staphylococcus au-reus (MRSA) at hospital admission in the Netherlands: the value of search and destroy and restrictive antibiotic use. J Hosp Infect. 2004;56:321-325 21. Calfee DP, Giannetta ET, Durbin LJ, Germanson TP, Farr BM. Control of endemic vancomycin-resistant enterococcus among inpatients at a university hospital. Clin Infect Dis. 2003;37:326-332 22. Knox KL, Holmes AH. Regulation of antimicro-bial prescribing practices: a strategy for controlling nosocomial antimicrobial resistance. Int J Infect Dis. 2002;6(suppl 1):S8-S13

23. Thomas AR, Cieslak PR, Strausbaugh LJ, Flem-ing DW. Effectiveness of pharmacy policies designed to limit inappropriate vancomycin use: a population-based assessment. Infect Control Hosp Epidemiol. 2002;23:683-688 24. Allegranzi B, Luzzati R, Luzzani A, et al. Impact of antibiotic changes in empirical therapy on antimicrobial resistance in intensive care unit-acquired infections. J Hosp Infect. 2002;52:136-140 25. Geissler A, Gerbeaux P, Granier I, Blanc P, Facon K, Durand-Gasselin J. Rational use of antibiotics in the intensive care unit: impact on microbial resistance and costs. Intensive Care Med. 2003;29:49-54 26. Saizy-Callaert S, Causse R, Furhman C, Le Paih MF, Thebault A, Chouaid C. Impact of a multidisciplinary approach to the control of antibiotic prescription in a general hospital. J Hosp Infect. 2003;53:177-182 27. Shaikh ZH, Osting CA, Hanna HA, Arbuckle RB, Tarr JJ, Raad II. Effectiveness of a multifaceted infection control policy in reducing vancomycin usage and van-comycin-resistant enterococci at a tertiary care cancer centre. J Hosp Infect. 2002;51:52-58 28. Thomas C, Riley TV. Restriction of third generation cephalosporin use reduces the incidence of Clostridium diffi cile-associated diarrhoea in hospitalised patients. Commun Dis Intell. 2003;27(suppl):S28-S31 29. Gould IM. Antibiotic policies and control of resis-tance. Curr Opin Infect Dis. 2002;15:395-400 30. Bonten MJ. Prevention of infection in the intensive care unit. Curr Opin Crit Care. 2004;10:364-368 31. Madaras-Kelly K. Optimizing antibiotic use in hospi-tals: the role of population-based antibiotic surveillance in limiting antibiotic resistance. Insights from the So-ciety of Infectious Diseases pharmacists. Pharmaco-therapy. 2003;23:1627-1633 32. Moro ML, Petrosillo N, Gandin C. Antibiotic policies in Italian hospitals: still a lot to achieve. Microb Drug Resist. 2003;9:219-222 33. Diekema DJ, Boots Miller BJ, Vaughn TE, et al. An-timicrobial resistance trends and outbreak frequency in United States hospitals. Clin Infect Dis. 2004;38:78-85 34. The SENIC Project. Am J Infect Control. 1980;111(special issue):465-653 35. Zoutman DE, Ford BD, Bryce E, et al. The state of infection surveillance and control in Canadian acute care hospitals. Am J Infect Control. 2003; 31:266-273 36. Smith DL, Levin SA, Laxminarayan R. Strategic in-teractions in multi-institutional epidemics of antibiotic resistance. Proc Natl Acad Sci U S A. 2005;102:3153-3158

37. Patterson JE, Hardin TC, Kelly CA, Garcia RC, Jor-gensen JH. Association of antibiotic utilization mea-sures and control of multiple-drug resistance in Kleb-siella pneumoniae. Infect Control Hosp Epidemiol. 2000;21:455-458 38. Elliott P. Recognising the psychosocial issues in-volved in hand hygiene. J R Soc Health. 2003;123:88-94 39. Larson EL, Aiello AE, Cimiotti JP. Assessing nurses’ hand hygiene practices by direct observation or self-re-port. J Nurs Meas. 2004;12:77-85 40. O’Boyle CA, Henly SJ, Larson E. Understanding ad-herence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29:352-360 41. Pittet D. The Lowbury lecture: behaviour in infection control. J Hosp Infect. 2004;58:1-13 42. Gould D. Systematic observation of hand decon-tamination. Nurs Stand. August 4-10, 2004;18:39-44 43. Jumaa PA. Hand hygiene: simple and complex. Int J Infect Dis. 2005;9:3-14 44. Stone PW, Clarke SP, Cimiotti J, Correa-de-Araujo R. Nurses’ working conditions: implications for infectious disease. Emerg Infect Dis. 2004; 10:1984-1989

This research was funded in part by the Center for Interdisciplinary Research on Antimicrobial Research, CIRAR, http://www.cumc.columbia.edu/dept/nursing/CIRAR/, funded by the National Center for Research Resources, P20 RR020616, and by Impact of Hand Hy-giene Guideline on Infections and Costs (National Insti-tute of Nursing Research, 1 RO1 NR008242).

Elaine L. Larson, RN, PhD, Dave Quiros, MS, Tara Giblin, RN, MPH, and Susan Lin, DrPH, School of Nursing (E.L.L., D.Q., T.G., S.L.) and Mailman School of Public Health (E.L.L.), Columbia Univer-sity, New York, NY

None of the authors have confl icts of interest or rel-evant proprietary interests.

Reprinted with permission, American Journal of Critical Care, February 2007.

Thank you to Liko North America and Prevent, Inc. for sponsoring the AOHP

Annual Business Luncheon at the 2007 National Conference on Friday, September 28 in Savannah.

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Membership/SubscriptionsAddress requests for information to AOHP Head-quarters, 109 VIP Drive, Suite 220, Wexford, PA 15090; (800) 362-4347; Fax: (724) 935-1560; E-mail: info@aohp.org.

Journal AdsAddress requests for information to AOHP Headquarters at (800) 362-4347

Moving?Bulk mail is not forwarded! To receive your Journal, please notify our business offi ce of any changes: AOHP Headquarters, 109 VIP Drive, Suite 220, Wexford, PA 15090; 1-800-362-4347; Fax: (724) 935-1560; E-mail: info@aohp.org. Upcoming AOHP Conferences2008 September 17-20: Denver, CO2009 September 16-19: Portland, OR

All material written directly for the Journal of the Association of Occupational Health Professionals in Healthcare is peer reviewed.

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MANAGE EMPLOYEE HEALTH IN LESS TIME.Employee health professionals – stop

racing against the clock. The Respond

software tracks and schedules tests,

exams, vaccinations, plus exposure

follow-ups and more. It even takes

the hassle out of OSHA reporting.

Respond puts time on your side,

so you can prevent problems, not

chase them.

Give ICPA a call today -

It’ll only take a minute.

800-426-8015

www.icpa.net

Ask about new Version 4.5!

The 2007 AOHP National Conference Syllabus is now

available in both CD and binder format.

Syllabus BinderMember price - $40

Non-member price - $50

Syllabus CDMember price - $20

Non-member price - $30

Prices include shipping and handling

To order, visit www.aohp.org, call AOHP Headquarters at 1-800-362-4347,

or email info@aohp.org

Getting Started on the Road – Do you think that GS on the road is only for a new OH professional? Well, think again! AOHP hosted 5 programs throughout the country in 2007 and our feedback supports this fi nding: even the seasoned professional can benefi t from this program.

For more details about hosting or attending a program in your area, contact AOHP HQ at 800 326-4347 or email info@ahop.org.

109 VIP Drive, Suite 220Wexford, PA 15090

www.aohp.org

Address Service Requested

PRSRT STDU.S. Postage

PAIDWarrendale, PAPermit No. 20

Congratulations! We have 79 new members who were recruited through the “Recruit Our Colleagues—ROC” cam-paign! AND . . . because of your outstanding efforts, the Board has agreed to continue our campaign through June 2008 . . . AND . . . you will once again have the opportunity to win fabulous prizes for your recruitment efforts!

One Grand Prize -2008 AOHP Conference Registration plus 4 nights hotel accommodations will be awarded to the one member who recruits the highest number of new members >/=15 members through June 30, 2008. If no member recruits 15 new members, the member who recruits the greatest number under 15 will receive a 2008 conference registration!

One 2nd Place Prize-The member who recruits the second highest number of new members will be awarded a FREE one-year membership to AOHP.

AND . . . The Chapter that recruits the most members will be awarded $500 to be used at their discretion to support their members!

What a “ROC” ’N Good Time with AOHP . . .AND . . . the beat goes on … AND on … AND on!

In the event of a tie, a drawing will be held to select the prize winners.

AND . . . There’s MORE . . . For all current AOHP members . . . if you RENEW your member-ship prior to December 31, 2007, your name will be entered into a drawing to win a free 2008 AOHP National Conference Registration!

There are so many great reasons to be a member of AOHP—THE organization that is dedicated to the health and safety of healthcare workers!

We welcome your comments on how we can continue to enhance our membership recruitment efforts. Thanks to each and every one of you for your active participation . . . AND . . . thanks for ROC’N for AOHP.

JoAnn Shea, ARNP, MS, COHN-SMembership Chair