CContact hour instructions, objectives, and accreditation information may be found on page 12

FEATURES

Health Care Reform & Issues in Nursing . . . . . . . . . . . . . . . . . .3

Medical-Surgical Nurses Week Celebration Highlights . . . . . . .8

Healthy Work Environments . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Back to Basics: A Medical-Surgical Orthopedic Unit’s Quest to Decrease Pressure Ulcers . . . . . . . . . . . . . . .16

NEWS

Frequently Asked Questions about MSNCB . . . . . . . . . . . . . .13

MSNCB Board of Directors Changes . . . . . . . . . . . . . . . . . . .13

Chapter News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Your Vote Shapes the Future of AMSN . . . . . . . . . . . . . . . . . .22

We Are Who You Are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

OFFICIAL NEWSLETTER

Volume 21 – Number 1January/February 2012

Patients requiring chest drainage need specialized equipment and nursing management in order toachieve optimal outcomes. Individuals with chest tubes are commonly admitted to medical-surgical units.This article will review the reasons chest drains are different from other drains, discuss how chest tubecollection devices operate, and how to apply these concepts to the care of a patient with a chest tube.

Chest drains remove blood, pleural fluid, and/or air from the lungs’ pleural space while preventing airfrom entering the chest cavity. When air enters the pleural space, a portion or the entire lung may col-lapse (pneumothorax). As fluid or air enters the pleural space and becomes trapped in the chest, a ten-sion pneumothorax may result, causing progressive lung collapse, a medialstinal shift, and hemodynamiccompromise. A tension pneumothorax, if untreated, is fatal (Leigh-Smith & Harris, 2005). Therefore, a chesttube has three functions: 1) to drain fluid and/or air from the chest, 2) to prevent air from entering thechest creating a pneumothorax, and 3) to control the level of suction (if suction is being used) to facilitatere-expansion of the lung.

Chest drainage units (CDUs) consist of three separate chambers in one device: one chamber collectsthe chest drainage, one prevents air from entering the chest, and the third chamber controls suction.Figures 1 and 2 show examples of CDUs.

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CNECONTINUING

NURSINGEDUCATION

Cynthia A. Frazer

President’sMessage

Reader ServicesMedSurg Matters!Academy of Medical-Surgical NursesEast Holly Avenue, Box 56Pitman, NJ 08071-0056(856) 256-2300 • (866) 877-AMSN (2676)Fax (856) 589-7463Email: amsn@ajj.comWeb site: www.amsn.org

MedSurg Matters! is owned and publishedbimonthly by the Academy of Medical-SurgicalNurses (AMSN). The newsletter is distributed tomembers as a direct benefit of membership.Postage paid at Bellmawr, NJ, and additional mailingoffices.

AdvertisingContact John Schmus, Advertising Representative, (856) 256-2315.

Back IssuesTo order, call 866-877-AMSN (2676).Editorial ContentAMSN encourages the submission of news itemsand photos of interest to AMSN members. By virtueof your submission, you agree to the usage and edit-ing of your submission for possible publication in theAMSN newsletter, Web site, and other promotionaland educational materials.

To send comments, questions, or article sugges-tions, or if you would like to write for us, contactthe Editor at msmnews@ajj.com.

AMSN Publications and ProductsTo order, call 866-877-AMSN (2676), or visit ourWeb site: www.amsn.org.

ReprintsFor permission to reprint an article, call 866-877-AMSN (2676).

IndexingMedSurg Matters! is indexed in the CumulativeIndex to Nursing and Allied Health Literature(CINAHL).

© Copyright 2012 by AMSN. All rights reserved.Reproduction in whole or part, electronic ormechanical without written permission of the pub-lisher is prohibited. The opinions expressed inMedSurg Matters! are those of the contributors,authors and/or advertisers, and do not necessarilyreflect the views of AMSN, MedSurg Matters!, or itseditorial staff.

Publication Management is provided byAnthony J. Jannetti, Inc., which is accred-

ited by the Association ManagementCompany Institute.

Volume 21 – Number 1January/February 2012

Sandra D. Fights

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Are You Ready to Take the AMSN 2012 Challenge?

Over the past couple of years, AMSN has been working to strengthen the associationand the specialty practice of medical-surgical nursing. The Board of Directors (BOD) hasdeveloped a strategic plan that helps us focus our efforts, utilize our resources, andstrengthen our relationships with other organizations within health care. Connecting withorganizations with similar concerns and interests promotes medical-surgical nursing as aspecialty in two ways: 1) by increasing the awareness of the medical-surgical nurse’s role inthe care of patients, and 2) by increasing the visibility of AMSN as a professional nursingorganization for medical-surgical nurses. AMSN is able through affiliations to participate ingroups working in the national arena on the big issues that impact nursing.

At a recent meeting of the Nursing Organizations Alliance, I listened to the leadersof other nursing organizations talk about their membership, what they had accomplishedand future work for their associations. One of the associations reported a membership of93,000. I was aghast! Having 93,000 nurses in an organization is incredible. I discovered thedues for the other organization to be comparable to AMSN dues. The services and prod-ucts offered in many ways were similar. With the resources provided by larger member-ship, the organization is able to do more in the areas of research, development of thenurse, and advocacy for patients and nurses. You’re probably wondering to which organi-zation I am referring. Yes, it is our critical care colleagues, the American Association ofCritical-Care Nurses (AACN). This association has been in existence much longer thanAMSN and they have done an excellent job in encouraging critical-care nurses to joinAACN.

According to the 2008 National Sample Survey of Registered Nurses, there are600,000 nurses practicing in the specialty of medical-surgical nursing (Health Resourcesand Services Administration, 2010). When I thought of that number – 600,000 – I won-dered, “Where is everyone?” The AMSN membership is nearly 9,000. In essence, the asso-ciation with 9,000 members is working to develop, maintain, and advocate for the prac-tice of the 600,000.

Let’s take a moment to answer the question, “What does membership in AMSN pro-vide?” For me, one of the most important benefits is the connection I make with othernurses through AMSN. I connect with them through AMSN activities, email, convention,and even Facebook! When I am faced with a question about “what do other places do?”I call on my AMSN connections for information and advice.

Previously, I could not be as involved as I wanted in AMSN because of other respon-sibilities in my life. However, I was able to stay in contact and continue to learn and growthrough the publications offered through AMSN.

I love our award-winning newsletter. MedSurg Matters! is a peer-reviewed newsletterthat includes at least one continuing nursing education article in each issue. Did you knowthe newsletter was peer-reviewed? I am proud that our association realizes the impor-tance of having peer review in our newsletter to increase the reliability and validity of theinformation published. The newsletter also provides association news and updates, givingthe AMSN local chapters an opportunity to share their activities and successes at the locallevel with our national members.

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Regulating Patient Staffing: A Complex Issue

Robin HertelNurse staffing has always been a complex issue, but recently it hastaken on renewed importance. There are currently four legislativeproposals in the U.S. House and Senate addressing staffing, withmultiple states also taking on this issue. Research into increasedstaffing levels is mixed. While increases in staffing increase job sat-isfaction among nurses, research fails to demonstrate a decreasein either patient falls or the development of pressure ulcers.Multiple staffing models and terminology also complicate thisissue. This article presents the proposed legislation, looks at prosand cons of staffing legislation, evaluates different staffing models,and discusses implications for practice.

The issue of nursing care and patient staffing ratios is not newto medical-surgical nurses. It took on national importance in 1996with the release of an Institute of Medicine (IOM) report that eval-uated nurse staffing and patient safety (Wunderlich, Sloan, & Davis,1996). Patient staffing ratios have recently taken on renewed impor-tance due to patients being better informed, higher acuity levels,budgetary concerns which are resulting in cutbacks at every level ofhealth care, and the aging of the nursing workforce (Bolton et al.,2007; Jennings, 2008; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007b;Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). There isa lively debate at every level of health care about the appropriateway to manage the patient load that registered nurses (RNs) can andshould take on. Nurses are dedicated to the safety of their patients,working diligently toward positive patient outcomes. In order to suc-ceed, patient-staff ratios must be reasonable. Financial aspects ofhealth care look to the bottom numbers, with payment tied to diag-nosis related groups (DRGs) and hospital-acquired problems such asfalls, pressure ulcers, and urinary tract infections (Kane et al., 2007b).Health care leaders seek to ensure care is delivered that will meetpatient needs while securing a profit for the hospital. Hospital admin-istrators must make certain the continued financial viability of theinstitution, adequate staffing, and positive patient outcomes, as wellas keep up with improving technological advances.

The varied agendas and the inability of nurses, hospital adminis-trators, and financial experts to communicate toward a single pur-pose, as well as the complexity of meeting staffing needs, have movedthe issue into the political arena (Douglas, 2010; Needleman et al.,2006). Legislators at the state and national level are attempting toresolve the issue. California implemented state mandated nurse-patient staffing levels in 2003. Twenty-three other states (includingIllinois, Maine, Nevada, Ohio, and Oregon) are now considering orhave passed staffing legislation (Douglas, 2010) to implement man-dated staffing ratios, use acuity levels to determine staffing needs, orto develop staffing committees with staff nurses as members.

National Legislation to Regulate Nurse-PatientStaffing Ratios

There are currently four separate pieces of legislation thathave been introduced in both the United States House and Senatethat address nurse-patient staffing ratios (see Table 1). These billspropose two different models of addressing nurse staffing: the useof a committee to develop acuity models and a strict nurse-to-patient ratio model.

Support for Regulating Nurse-Patient StaffingRatios

Patient safety is at the core of all proposed national and statelegislation. In support of patient safety, research studies demon-strate a decrease in patient mortality (1.24% reduction) with anincrease in RN staffing (Pearson et al., 2004). Higher RN-patientstaffing ratios are also associated with fewer incidents of failure-to-rescue, cardiac arrest, hospital-acquired pneumonia, and otheradverse events (Kane et al., 2007b). Understaffing and overtimehours have been associated with increases in patient mortality, hos-pital-acquired infections, shock, and bloodstream infections (Kane etal., 2007b). While research shows a link between nurse-patientstaffing ratios and patient outcomes, other factors to be consideredinclude “occupational health issues (back injuries and needlestickinjuries) and psychological states and experiences (like burnout)that may represent precursors for nurse turnover from specific jobsas well as the profession” (Clark & Donaldson, 2008, p. 124). A sur-vey by Buerhaus (2009) revealed 60% of nurses felt minimum nurse-patient staffing ratios should be mandated.

A study completed by Aiken and colleagues (2010) found 74%of California staff nurses thought the quality of care had improvedas a result of mandated staffing legislation. This study also reporteda significantly lower percentage of burnout and increased levels ofjob satisfaction among California nurses following implementationof the mandated staffing legislation. Other findings in this studyinclude decreases in patient and family complaints and a decrease inworkplace (horizontal) violence.

Support for NOT Regulating Nurse-PatientStaffing Ratios

Conversely, a number of studies demonstrate that improvednurse-patient ratios do not positively impact quality of care, safety,or length of stay (Bolton et al., 2007; Clark, 2005; Greenberg, 2006).A report published by the California Nursing Outcomes Coalition(2005) evaluated the impact of the mandated nurse-patient ratioand found “no statistically significant changes in the patient safetyand quality outcomes studies, the incidence of patient falls, and theprevalence of pressure ulcers” (Bolton et al., 2007, p. 239). Similarresults were obtained by Bolton and colleagues (2007) and Lake andCheung (2006) in follow-up studies that found no statistically signif-icant decrease in the number of patient falls or the development ofhospital-acquired pressure ulcers with the implementation of man-dated nurse-patient ratios.

Although designed to ensure full and constant coverage ofpatients by professional nurses, current California legislation andUnited States Senate bill S.992, National Nursing Shortage Reformand Patient Advocacy Act (Boxer, 2011), state the ratios must be

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Health Care Reform & ISSUES IN NURSING

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Academy of Medical-Surgical Nurses www.amsn.org

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Legislation Sponsor Summary Status

H.R. 876Registered Nurse Safe Staffing Actof 2011

Capps (CA) 6 co-sponsors

Requires all Medicare participating hospitals toestablish nurse staffing committees toimplement and oversee hospital-wide staffingplan for nursing services. Plan requires anappropriate number of registered nurses pro-vide direct patient care in each unit and oneach shift to ensure staffing levels that addressthe unique characteristics of the patients andhospital units and results in the delivery ofsafe, quality patient care.

Referred to Subcommittee onHealth

H.R. 2187To amend the Public Health ServiceAct to establish direct care regis-tered nurse-to-patient staffing ratiorequirements in hospitals and forother purposes

Shakowsky (IL) 12 co-sponsors

This legislation was introduced June 15, 2011.The text is not yet available, but will be areflection of S.992.

Referred to Committees on Waysand Means and Commerce

S.58Registered Nurse Safe Staffing Actof 2011

Inouye (HI) No co-sponsors

Requires all Medicare participating hospitals toestablish nurse staffing committees toimplement and oversee hospital-wide staffingplan for nursing services. Plan requires anappropriate number of registered nurses pro-vide direct patient care in each unit and oneach shift to ensure staffing levels that addressthe unique characteristics of the patients andhospital units and results in the delivery ofsafe, quality patient care.

Referred to Committee on Finance

S.992National Nursing Shortage Reformand Patient Advocacy Act

Boxer (CA)No co-sponsors

Requires all hospitals to implement nurse-patient ratios as follows:1:1 – trauma emergency units1:1 – OR units, providing at least one addi-tional person to serve as scrub assistant1:2 – critical care units1:3 – emergency room, step-down, pediatrics,telemetry, ante-partum, labor and delivery1:4 – medical-surgical, intermediate care nurs-ery, psychiatric and other specialty care1:5 – rehabilitation and skilled nursing units1:6 – well baby nursery, postpartum (3 cou-plets)Hospitals may NOT average the number ofpatients and total number of direct carenurses on any unit, may NOT impose manda-tory overtime requirements, and MUST pro-vide direct care registered nurse coverage foranother direct care registered nurse duringbreaks, meals, and other routine, expectedabsences from the unit.

Referred to Committee on Health,Education, Labor, and Pensions

Table 1.Proposed Nurse-Patient Staffing Ratio Legislation

Source: Adapted from Library of Congress, 2011.

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met at all times, requiring float nurses to cover breaks. This in itselfmay pose a safety issue related to “increased handover communica-tions requirements with potential for error, variations in skills andcompetencies, [and] variations in continuity” (Douglas, 2010, p. 121).

Problems Associated with Regulating Nurse-Patient Staffing Ratios

One of the primary difficulties in developing a comprehensiveand accurate staffing bill is the number of variables that affectstaffing and patient outcomes along with the multiple means ofmeasuring staffing needs. Measures of staffing are often calculatedover a 1-year period looking at, for example, day shifts in a quarter,perhaps across all units of the hospital. Staffing levels on differentunits should reflect differences in patient populations and illnessseverity. Various types of staffing measures add to the complexity ofthe issue: patient-to-nurse ratio, hours of nursing care provided perpatient day (HPPD), and full-time equivalent (FTE) positions workedin relation to average patient census (ADC) (Coffman, Seago, &Spetz, 2002; Douglas, 2010). While the ratio of unlicensed personneland licensed practical (or vocational) nurses to RNs is oftenaccounted for, additional staffing-related characteristics include thequalifications of the staff members, years of experience, professionalcertification of the staff, the use of contract or agency staff, andwhether or not the charge nurse, nurse educators, and othernurses not assigned a patient load are included in the staffing meas-ure.

There may be differences in measuring acuity in different states(Aiken et al., 2010). Additionally, some facilities may staff with ratiosof FTEs of RNs per patient day or occupied bed, while another mayutilize a patient-to-nurse ratio per shift (Kane et al., 2007b). The abil-ity to develop a comprehensive staffing plan and legislation is fur-ther limited by the inconsistency in operational definitions of nurs-ing staff patterns and methods to measure patient acuity (Kane etal., 2007a).

The inability to measure the “work” of the nurse contributesto the complexity of this issue. For example, the patient flow(admissions, discharges, patients returning from surgeries, and trans-fers to and from other units) can result in nurses providing care formany more patients in a day than what is reflected in the RN hoursper patient day or nurse-patient staffing ratio (Needleman et al.,2011).

There are financial factors to consider when establishing a setnurse-to-patient staffing ratio. Hospitals are paid a fixed rate underthe DRGs system that does not reflect the quality of care thepatient has received. In addition, there are a number of hospital-acquired conditions (e.g., infections, pressure ulcers) that are notcovered by Medicare/Medicaid and many privately held insurancegroups (Department of Health and Human Services, 2010).Regulating staffing ratios would place an increased financial burdenon the hospital. To meet this increase in cost, hospitals may considerreducing support staff positions, which may increase the overall bur-den on the RN (Spetz, 2005). In a study completed by Aiken and col-leagues (2010), there was a substantial decrease in the use of unli-censed assistive personnel (34%) and non-nursing support servicessuch as clerical help and housekeeping services (27%) when staffingratios were regulated. The fact remains that the work done by these

entities does not go away, but is instead picked up as additionalnursing responsibilities.

A second financial factor associated with mandated nursestaffing ratios would be a facility’s ability to invest in medical tech-nology and equipment to improve the quality of care. “Some ofthese investments, such as electronic medical records and medicalequipment with state-of-the art safety features, can greatly reducehuman errors in care delivery. They can also ease the demandsplaced on nurses, perhaps even more so than increases in nurse-to-patient ratios can” (Coffman et al., 2002, p. 61).

The nursing shortage must also be considered when discussingmandated staffing levels. While regulating the number of patients anurse cares for may make returning to inpatient nursing moreattractive to professionals and may increase the interest of theyoung adult in nursing as a profession, increasing the amount of non-nursing work performed by the RNs could reduce this potentialwork pool. In addition, increased interest in nursing does not auto-matically result in increased numbers of nurses due to the multipleissues faced by nursing programs such as the aging nurse faculty,insufficient salaries for nursing faculty, and limitations on clinicalspace. Hospitals located in areas of the country where nurses arein short supply may be forced to divert patients or close theirdoors if a strict nurse-patient ratio is mandated.

Nurse-Patient Staffing Ratio MethodsThe patient acuity-based staffing commonly used across the

United States is a method that utilizes a patient classification system(PCS) to predict patient requirements for care and is used to man-age nurse staffing, costs, and quality of care (Jennings, 2008). ThePCS, which requires adjustments to staffing based on patient diag-nosis and co-morbidities, is not an ideal system. Douglas (2010) listsno fewer than 36 variables that must be considered on each unit forstaffing decisions (see Table 2). In addition, validity and reliability ofPCSs are infrequently monitored and as a result, often lack credibil-ity among staff nurses and administrators (Jennings, 2008). The use-fulness of a PCS is further compromised because it does notaccount for shift-to-shift fluctuations in nurse staffing that have animportant influence on quality of care.

Terminology also varies between hospitals and states withregard to the patient classification system. Some facilities may basestaffing on DRGs while others assess and classify “patients accord-ing to their need of care as well as the activities that are necessaryto fulfill the needs of the care process during a certain time period”(Rainio & Ohinmaa, 2005, p. 675). Yet another system involves analy-sis of six subsections of care provided by nurses: planning and coor-dination of care, symptoms of disease, nutrition and medication,personal hygiene, activity and movement, and teaching (Rainio &Ohinmaa, 2005).

The use of a standardized staffing method does not produceaccurate results. For instance, the Medicare’s Case Mix Index (CMI)is often used to make comparisons of quality across hospitals (Mark& Harless, 2011). However, the end result is often dependent uponwhich angle one is looking at. “Administrators tend to view a higherCMI as a reflection that the patients require more resources, result-ing in higher costs” (Mark & Harless, 2011, p. 107). In reality, this isnot always the case. Mark and Harless (2011) illustrated the dispar-ity involved with the CMI system by comparing two patient scenar-

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Academy of Medical-Surgical Nurses www.amsn.org

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ios: one severely ill patient who is receiving palliative care and apatient who is not as ill but requires extensive education and plan-ning prior to discharge. The first patient has an elevated CMI num-ber and the second patient has a low CMI number. Utilizing the CMImodel, more resources (staffing) would be extended to the pallia-tive care patient than the one in need of additional education andresources on discharge.

Implications for Nursing PracticeThe literature review has not yielded any evidence-based min-

imum staffing ratios (Bolton et al., 2007; Jennings, 2008; Needleman,Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Currently, cliniciansand managers set nurse-patient staffing ratios based on their expe-rience and extrapolations of research findings and the bottom finan-cial line. In the absence of any legal mandate to regulate staffing, itappears the best practice is to benchmark staffing and outcomesagainst peers along with avoiding extremes in low staffing and highadverse events.

Even this approach does not guarantee positive results. Astudy evaluating California’s mandated staffing and the implicationsfor other states found that while 88% of California nurses on med-ical-surgical units met the mandated benchmarks for staffing (1:5ratio), the results are not so positive for those states in which noregulation exists (Aiken et al., 2010). In the study, which also evalu-

ated hospitals and nurse staffing in New Jersey and Pennsylvania,benchmarks for staffing on medical-surgical units were met only19% and 33% of the time, respectively.

A method of staffing that incorporates unit nurses’ input todevelop nurse staffing plans based on nurse-sensitive patient out-comes may be warranted. This method would address staffing needswithout the rigid mandates and provide increased opportunities fornurses to play a direct role in staffing decisions. “Whatever solutionwe stand behind must give the nurse the power to make staffingdecisions and to override models, including ratios, when they don’tmake sense and to have the authority to use their expertise in thebest interest of patients, the care team, and the hospital” (Douglas,2010, p. 122).

Conclusion The debate over nurse-patient staffing ratios is complex and

introducing politicians into the mix increases the complexity. The pri-mary issue remains the delivery of safe, quality, and cost-effectivepatient care; this can only be accomplished if/when nurses, administra-tors, financial leaders, and politicians work together and respect oneanother’s point of view to bring resolution to this complex problem.It is vital that nurses take an active role in being informed and partici-pate in developing a nurse-patient system to determine a staffing ratiothat promotes patient safety and positive patient outcomes.

Table 2.Staffing Decision Variables

1. Number of patients 13. Number of RNs 25. Individual nurse (staff dynamics)

2. Range of conditions 14. Number and skill mix of staff 26. Patient satisfaction

3. Intensity of situation 15. Experience level of staff 27. Nurse satisfaction

4. Severity of illness 16. Special credential requirements 28. Ancillary and support staff availability

5. Stage of illness 17. Continuity of care 29. Physician preferences

6. Family situation/needs 18. Role and skill competencies 30. Variations in technology

7. Safety 19. Fatigue considerations 31. Policies and procedure requirements

8. Quality 20. Setting/environment 32. Legislative and regulatory requirements

9. Education requirements 21. Physical plant 33. Safety considerations

10. Treatment requirements 22. Working conditions 34. Quality considerations

11. Observation and interventionrequirements

23. Culture influences 35. Budget considerations

12. Admissions, discharges, and transfers 24. Team dynamics 36. Performance pressures (scorecards,benchmarks, and justifying variances)

Source: Douglas, 2010, p. 7. Reprinted with permission.

Wunderlich, G.S., Sloan, F.A., & Davis, C.K. (Eds.). (1996). Nursing staff in hos-pitals and nursing homes. Is it adequate? Washington, DC: Institute ofMedicine, National Academies Press.

Robin Hertel, MSN, RN, CMSRN, is a Nursing Faculty Member,North Central Kansas Technical College, Hays, KS. She is Secretaryof the AMSN Board of Directors and a former chairperson of theLegislative, Policies, and Issues Committee.

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ReferencesAiken, L., Sloane, D., Cimiotti, J., Clarke, S., Flynn, L., Seago, J.A., … Smith, H.

(2010). Implications of the California nurse staffing mandate for otherstates. Health Services Research, 45(4), 904-921.

Bolton, L., Aydin, C., Donaldson, N., Brown, D., Sandhu, M., Fridman, M., &Aronow, H. (2007). Mandated nurse staffing ratios in California: Acomparison of staffing and nursing-sensitive outcomes pre- andpostregulation. Policy, Politics & Nursing Practice, 8(4), 238-250.

Boxer, B. (2011). National nursing shortage reform and patient advocacy act.Washington, DC: Library of Congress. Retrieved fromhttp://hdl.loc.gov/loc.uscongress/legislation.112s992

Buerhaus, P. (2009). Avoiding mandatory hospital nurse staffing ratios: Aneconomic commentary. Nursing Outlook, 57(2), 107-112.

Clark, S.P. (2005). The policy implications of staffing-outcomes research.Journal of Nursing Administration, 35(1), 17-19.

Clark, S.P., & Donaldson, N.E. (2008). Nurse staffing and patient care qualityand safety. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for HealthcareResearch and Quality. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2676/pdf/ch25.pdf

Coffman, J., Seago, J.A., & Spetz, J. (2002). Minimum nurse-to-patient ratios inacute care hospitals in California. Health Affairs, 21(5), 53-64.

Department of Health and Human Services. (2010). Hospital acquired conditions(HAC) in acute inpatient prospective payment system (IPPS) hospitals.Washington,DC: Department of Health and Human Services. Retrieved fromhttp://www.cms.gov/HospitalAcqCond/downloads/HACFactsheet.pdf

Douglas, K. (2010). Ratios – If only it were that easy. Nursing Economic$,28(2), 119-125.

Greenberg, P.B. (2006). Nurse-to-patient ratios: What do we know? Policy,Politics & Nursing Practice, 7(1), 14-16.

Jennings, B. (2008). Patient acuity. In R.G. Hughes (Ed.), Patient safety and qual-ity: An evidence-based handbook for nurses. Rockville, MD: Agency forHealthcare Research and Quality. Retrieved fromhttp://www.ncbi.nlm.nih.gov/books/NBK2680

Kane, R., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007a). Nurse staffing andquality of patient care. Rockville, MD: Agency for Healthcare Research andQuality. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK38315/

Kane, R., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007b). The associa-tion of registered nurse staffing levels and patient outcomes. MedicalCare, 45(12), 1195-1204.

Lake, E., & Cheung, R. (2006). Are patient falls and pressure ulcers sensitiveto nurse staffing? Western Journal of Nursing Research, 28(6), 654-677.

Library of Congress. (2011). Legislation in current congress. Retrieved fromhttp://www.thomas.gov

Mark, B.A., & Harless, D.W. (2011). Adjusting for patient acuity in measure-ment of nurse staffing: Two approaches. Nursing Research, 60(2), 107-114.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002).Nurse-staffing levels and the quality of care in hospitals. New EnglandJournal of Medicine, 346(22), 1715-1722.

Needleman, J., Buerhaus, P., Pankratz, V., Leibson, C., Stevens, S., & Harris, M.(2011). Nurse staffing and inpatient hospital mortality. New EnglandJournal of Medicine, 364(11), 1037-1045.

Needleman, J., Buerhaus, P., Stewart, M., Zelevinsky, K., & Mattke, S. (2006).Nurse staffing in hospitals: Is there a business case for quality? HealthAffairs, 25(1), 204-211.

Pearson, S.D., Allison, J.J., Kiefe, C.I., Weaver, M.T., Williams, O.D., Centor,R.M., & Weissman, N.W. (2004). Nurse staffing and mortality forMedicare patients with acute myocardial infarction. Medical Care,42(12), 4-12.

Rainio, A.K., & Ohinmaa, A.E. (2005). Assessment of nursing managementand utilization of nursing resources with the RAFAELA patient classi-fication system case study from the general wards of one central hos-pital. Journal of Clinical Nursing, 14(6), 674-684.

Spetz, J. (2005). Public policy and nurse staffing: What approach is best?Journal of Nursing Administration, 35(1), 14-16.

• Nursing Research: It’s Easier Than You Think!

• The Nurse Education Imperative

• Eliminating Green to Go Green: Using Web Technology toIncrease Clinical Documentation

• Deep South Chapter #218 Recognized for Political and Legislative Activities

• Reinterpretation of the Controlled Substances Act:Implications for Nursing Practice, Patient Care, and Nursing Ethics

• Disseminated Intravascular Coagulation and itsRelativity to Med-Surg Nursing

Coming soon in…

How Did You Celebrate Med-Surg Nurses Week?

Medical-Surgical Nurses Week, held from November 1-7 annu-ally, is dedicated to nurses who work in the med-surg specialty. It’s atime to give acknowledgement and honor to the commitment of you,the med-surg nurse. Every year, we ask you to share how you cele-brated the week. These are a few responses we received.

Anne Arundel Celebrates with Full Support

Anne Arundel Medical Center in Annapolis, MD, celebratedwith some major support. The unit received the banner forOutstanding Inpatient Satisfaction for the quarter, presented byPresident and CEO Tori Bayless and Senior Vice President of PatientCare Services Sherry Perkins. They also received proclamation fromGovernor Martin O’Malley honoring all the med-surg nurses. Otherbig supporters were Clinical Director Christine Frost, SeniorDirector of Nursing Anne Marie Pessagno, Dr. Capstack and theMDCIS Group, and Dr. Woods and the Hospitalist Group. Thenurses also had lunch-and-learns, fun, and games through the week,with help from vendors LifeCare, Bright Star, and ProCareAmbulance Company. They had so much to do that they evenstarted a day early on October 31! As Jazmin Manlapaz, RN, said, “Itwas just so wonderful to be able to celebrate and enjoy oneanother’s company.”

Greater Evansville ChapterCelebrates with EducationThe Greater Evansville Chapter #324 celebrated by presenting

the 9th Annual Advances in Medical-Surgical Nursing 2011 at St.Mary’s Hospital in Evansville, IN. Speaker Barb Bancroft, MSN, RN,PNP, presented “50 Ways to Love Your Liver and Moon Pies, FrenchFries, and Thunder Thighs.” The chapter presented the Med-SurgNurses Week name badge ribbons to all attendees. Also, DeaconessHospital had a display case filled with information about AMSN andthe local chapter, and they proudly hung the poster from theSeptember/October issue of MedSurg Matters!

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Front row (l-r): Dianne Wong, RN; Jen Rouse, RN; Diane Leverance, PCT 11; CindySauerwin, RN; Jazmin Manlapaz, RN; AnnMarie Pessagno, RN (Senior Director);Mary Cohn, RN (Nurse Educator); Christine Frost, RN (Clinical DirectorMedSurg/SCU); and MaryAnn Julian, RN (Charge Nurse MedSurg). Back row (l-r): Elise Morris, RN; Shauna Johnson, PCT11; Nick Wolf, RN; and Lauren Stylc, RN.

Greater Southeastern MichiganChapter Celebrates with Freebies

The Greater South-eastern Michigan Chapter#301 treated med-surgnurses to some free good-ies during Medical-SurgicalNurses Week. The chapterprovided cake, popcorn,and lots of pens to thenurses at Providence ParkHospital in Novi.

Pictured (l-r): Ashley Klisz, Tiffany Barnett, KimDavidson, and Tania Dellalian.

Lebanon VA Celebrates with Trivia and TreatsThe Lebanon VA Medical Center in Lebanon, PA, cele-

brated the week by making each day’s menu special.November 1 was Root Beer Float Day, followed by pizza,subs, donuts, and salad. (Of course, lollipops were availableevery day.) Nurses also had a chance to earn prizes by cor-rectly answering questions displayed on the break room wall.Also, Nancy Elliott used the AMSN Web site to send a specialMed-Surg Nurses Week e-card to the whole group.

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Murphy Medical CenterCelebrates with Themes

Murphy Medical Center in Murphy,NC, knew what they were doing for Med-Surg Nurses Week. Each day had a theme,such as Crazy Hat Day, Team Jersey Day,Cookie Day, Crazy Sock Day, and GuessHow Many Day. A Grand AwardsCeremony gave awards like Med-Surg

Employee of the Year, ShiningStar, You Make a World ofDifference, and Leading byExample. The nurses were

served pizza and cake and were givencustom-printed candy bars and a cook-book containing recipes from theemployees. It was a great week!

Illinois Wesleyan UniversityCelebrates with History

The day before Med-Surg Nurses Week began,AMSN member Noël Kerr,PhD, RN, CMSRN (Assis-tant Professor, School ofNursing, Illinois WesleyanUniversity), had her studentsexplore nursing history andreflect on their own “call” toenter the nursing profession.Class met on Halloween, soshe encouraged them tocome to class in costume.Dr. Kerr dressed as the“Lady with the Lamp,” wear-ing an authentic Victoriandress patterned after photosof Florence Nightingale.Students listened to arecording of Nightingale’svoice and viewed historicalobjects linked to Night-ingale. Dr. Kerr taught thestudents about how

Nightingale discerned her call to become a nurse. The students thenwrote the beginning of their own story and described how they each

Noël Kerr dressed as Florence Nightingalefor a lesson on historic nursing.

decided to enter the nursing profession. Dr. Kerr plans to return theessays to each student in a sealed envelope upon their graduationwith instructions to open the envelope on the anniversary of theirfirst year working as an RN. At the end of class, students receivedcomplimentary copies of MEDSURG Nursing and AMSN informationalbrochures.

Academy of Medical-Surgical Nurses www.amsn.org

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Drainage Collection ChamberThe drainage collection chamber is designed to collect any

pleural fluid or blood draining from the chest. It is the largest cham-ber and is marked with graduations to record the amount of liquiddrainage (see the chamber on the right in Figures 1 and 2). Theamount of drainage present is marked on the drainage chambereach shift or at the prescribed frequency and recorded as output.The drainage chamber is never emptied; the CDU is replaced whenthe drainage chamber becomes full. The nurse should monitor theappearance of the drainage and document this at least once a shift.The chest tube drainage appearance and output may need to bedocumented more frequently than once a shift in cases where thepatient has a large amount of drainage immediately following sur-gery or if the nurse suspects the patient is having an unexpectedamount of drainage. If the chest tube was inserted to treat a pneu-mothorax, there may be little or no fluid drainage (Carroll, 2010;Teleflex Medical, 2009).

Water Seal ChamberThe middle chamber is designed to prevent air from entering

the chest while at the same time allowing air to escape from thepleural cavity if the patient has a pneumothorax (Teleflex Medical,2009). CDUs use a small chamber filled with water to reestablishnegative pressure in the pleural cavity (see the middle chamber inFigures 1 and 2). The water seal chamber is similar to a straw in aglass of water. When the patient inspires, the water in the water sealchamber moves up the chamber, the same way water moves up astraw when suction is applied to the straw. But no air enters thestraw. In the same way, the water seal prevents air from entering thechest tube. When the patient exhales, the increased pressure in thechest causes water to move down in the water seal chamber. Thisfluctuation of the water level in the water seal chamber with respi-ration is known as “tidaling” and is a normal finding (Carroll, 2010;Teleflex Medical, 2009). On the other hand, absence of tidaling is notnecessarily an abnormal finding. Absence of tidaling may mean thatthe lung has re-expanded and the chest tube is no longer neededor the tubing is obstructed with a kink, clot, or fibrous tissue(Carroll, 2010).

If the patient does have a pneumothorax, air is able to escapefrom the chest through the water seal chamber. Air escaping thepleural cavity can be seen as bubbles in the water seal chamber, justlike blowing into the straw will cause bubbling in the glass of water.Continuous bubbling on expiration in the water seal chamber isdescribed as an “air leak.”

All chest tubes should be routinely monitored for the presenceof an air leak. Information about the presence or absence of an airleak should be documented in the patient record and reported dur-ing patient hand-off communications. If the patient has a known pneu-mothorax and an air leak is present, that is a normal finding; the air isbeing evacuated from the chest according to plan. However, a new airleak in a patient who has not had one previously should be investi-gated immediately. A new air leak may be a sign of a new pneumo-thorax, or it may indicate a problem with the CDU. Disconnection ofthe chest tube or a hole in the drainage tubing will permit air to enterthe system and cause bubbling in the water seal chamber.

To determine the cause of a new air leak, the nurse canmomentarily clamp the chest tube near the patient’s chest (Carroll,2010; Teleflex Medical, 2009). If the air leak stops, it is being causedby air coming from the patient’s chest, a pneumothorax, and shouldbe promptly reported to the health care provider. If the air leakdoes not stop when the chest tube is clamped near the chest wall,the air leak is being caused by a disconnection or hole in the tubingleading to the collection device. The nurse can further locate theproblem by moving the clamp down the tubing until the air leakstops. If the air leak is caused by a loose connection, the connectioncan be tightened. If there is a leak in the CDU tubing or the CDUitself, the CDU should be replaced (Carroll, 2010).

Over time, water in the water seal chamber may evaporate.The level of water should be checked routinely and sterile wateradded to keep the water at the manufacturer’s recommended level(Teleflex Medical, 2009).

Some CDUs, known as “dry seal,” use a mechanical one-wayvalve to replace the water seal. Most dry seal CDUs will have an airleak detection chamber containing a small amount of water to assistin identifying air leaks (Carroll, 2010).

Suction Control ChamberThe third chamber is designed to precisely control suction.

Suction is not always used with chest tubes, but may be used toassist in the removal of thick drainage (as in empyema), bloody

Managing Chest Tubescontinued from page 1

Figure 1.Wet Suction Chest Drainage Unit

suction control collection chamberwater seal

Source: Created by Anne M. Frazer. Used with permission.

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866-877-2676 Volume 21 – Number 1

drainage, or large amounts of drainage. When suction is required, itis important that the level of suction be controlled to preventexcessive damage to lung tissue from the suction. Suction at -20 cmof water is the most common setting. The suction control tubing isconnected to the wall vacuum regulator and the vacuum control isadjusted to the manufacturer’s specifications (Carroll, 2010; TeleflexMedical, 2009).

Traditionally, CDUs use a chamber filled with water to controlthe level of suction. This type of CDU is called a “wet suction” unit(see Figure 1). The level of suction is determined by the height ofthe water column in the suction control chamber. Continuous bub-bles will be seen in the suction control chamber when the suctionis on. Bubbling in the suction control chamber is not an air leak, butis an expected finding in a wet suction CDU. The suction sourceshould be adjusted until there is gentle bubbling in the suction con-trol chamber. Over time, water will evaporate in the suction con-trol chamber and must be replaced in order to provide the orderedlevel of suction (Teleflex Medical, 2009).

“Dry suction” CDUs are a more popular choice (see Figure 2).A dry suction CDU uses a mechanical suction control rather thana water-filled chamber. The level of suction is set by means of a con-trol, usually a dial, on the collection device. The advantages of drysuction include the ease of set-up, quiet operation (the bubbling ina water suction chamber can be quite noisy), and no concerns withwater evaporation changing the level of suction (Carroll, 2010;Teleflex Medical, 2009).

Suction may usually be disconnected from both the “wet” and“dry” suction CDUs and the unit placed to water seal for brief peri-ods of time to permit ambulation or to transport the patient. Whenthe chest tube is placed to water seal, the suction port should beleft open to air. This allows air to escape the CDU and prevents atension pneumothorax from developing. Most CDUs do have asafety valve that prevents a tension pneumothorax from developingif the suction port is occluded (Carroll, 2010; Teleflex Medical,2009), but leaving the suction port open when not in use is prudent.

Care of the Patient with a Chest TubeCare of a patient who has a chest tube begins with assessment.

When assessing the chest tube function it is important to begin byassessing the patient. Changes in respiratory status could mean aproblem with the chest drainage. If palpation around the chest tubeinsertion site reveals crepitus, the patient likely has subcutaneousemphysema – air in the subcutaneous tissues – which can occur asa result of a malpositioned chest tube. Subcutaneous emphysema israrely dangerous, but if new or increasing should be reported to thehealth care provider (Cerfolio, Bryant, & Maniscalco, 2008). Table 1summarizes the assessment of a patient who has a chest tube.Chest tube dressings are not commonly changed unless soiled butshould be reinforced if loose (Carroll, 2010). Taping of connectorsites are determined by facility and/or physician preference.

In the past, chest tubes were routinely “stripped” in an effortto ensure adequate drainage. Stripping, or compressing the tubing atthe proximal end firmly with one hand while pulling distally thelength of the tube with the other hand, is no longer recommended(Halm, 2007). Stripping may cause excessive negative pressure in thechest and damage lung tissue. If clots obstruct the tube, milking, orgently squeezing or kneading the tubing, may be done to move theclots and relieve the obstruction.

1. Assess the patient’s respiratory status: lung sounds, pulseoximetry reading, and respiratory rate and effort

2. Assess the chest tube insertion site for intact dressing,drainage, and subcutaneous emphysema

3. Check the drainage tubinga. Character of drainageb. Connections tight and tapedc. Tubing free of obstructions and dependent loops

4. Check the CDUa. Collection chamber

i. Amount and character of drainageb. Water seal chamber

i. Presence or absence of air leakii. Presence or absence of tidalingiii. Water at level indicated by manufacturer

c. Suction chamberi. Suction level as orderedii. Suction port open to air if suction not in use

Figure 2.Dry Suction Chest Drainage Unit

suction control collection chamberwater seal

Source: Created by Anne M. Frazer. Used with permission.

continued on page 12

Table 1.Care of Chest Tubes

Academy of Medical-Surgical Nurses www.amsn.org

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Chest tubes should not be clamped without an order.Exceptions to this rule are that a chest tube may be clamped for afew moments while investigating an air leak or when changing a col-lection container. In some instances, the health care provider mayorder the chest tube to be clamped to verify that the patient willbe able to tolerate having the chest tube removed (Dev,Nascimiento, Simone, & Chien, 2007; Funk, Petrey, & Foreman,2009). If a chest tube is clamped, monitor the patient’s respiratorystatus closely. If the patient develops respiratory distress, unclampthe chest tube and notify the provider.

If a chest tube is accidentally removed, cover the insertion sitewith sterile, dry gauze (Carroll, 2010). If the patient has had an airleak in the CDU, be careful not to cover the site with an occlusivedressing, or a tension pneumothorax may result. The traditional rec-ommendation is to tape the dressing on only three sides to avoid atension pneumothorax. Notify the health care provider and moni-tor the patient’s respiratory status closely.

If a chest tube becomes disconnected and cannot be recon-nected to the original CDU or a replacement CDU quickly, the endof the chest tube may be submerged in a bottle of sterile water untilthe CDU can be replaced. The sterile water acts as a water seal toprevent pneumothorax (Carroll, 2010).

Chest Tube RemovalThe health care provider usually removes chest tubes at the

bedside. During removal of the chest tube, care must be taken toprevent air from entering the pleural space through the chest tubeinsertion site. The patient is instructed to hold his or her breathwhile the tube is removed and an occlusive dressing is immediatelyapplied (Dev et al., 2007). A chest x-ray is usually ordered to ensurethat the lungs remain expanded after the chest tube is removed. Thepatient’s respiratory status should be closely observed after a chesttube is removed (Carroll, 2010).

This review provides the medical-surgical nurse with informa-tion necessary to manage chest tubes confidently and to provide foroptimal patient outcomes.

ReferencesCarroll, P. (2010). Managing chest drainage. Retrieved from http://www.atri

ummed.com/EN/Chest_Drainage/Documents/continuing%20education%202010%20Online.pdf

Cerfolio, R.J., Bryant, A.S., & Maniscalco, L.M. (2008). Management of subcu-taneous emphysema after pulmonary resection. The Annals of ThoracicSurgery, 85(8), 1759-1763.

Dev, S.P., Nascimiento, B., Simone, C., & Chien, V. (2007). Videos in clinicalmedicine. Chest-tube insertion. New England Journal of Medicine,357(15), e15.

Funk, G.A., Petrey, L.B., & Foreman, M.L. (2009). Clamping thoracostomytubes: A heretical notion? Baylor University Medical Center Proceedings,22(3), 215-217.

Halm, M.A. (2007). To strip or not to strip? Physiological effects of chesttube manipulation. American Journal of Critical Care, 16(6), 609-612.

Leigh-Smith, S., & Harris, T. (2005). Tension pneumothorax – Time for arethink? Emergency Medicine Journal 22(1), 8-16.doi:10.1136/emj.2003.010421

Teleflex Medical. (2009). Understanding chest drainage. Retrieved fromhttp://www.teleflex.com/en/usa/ucd/index.php

Cynthia A. Frazer, MS, RN-BC, CMSRN, CNE, is an AssistantProfessor, Department of Associate Degree Nursing, EasternKentucky University, Richmond, KY.

Instructions For Continuing NursingEducation Contact Hours

Managing Chest TubesMSNN1201

To Obtain CNE Contact Hours1. For those wishing to obtain CNE contact hours, you must

read the article and complete the evaluation throughAMSN’s Online Library. Complete your evaluationonline and print your CNE certificate immediately, orlater. Simply go to www.amsn.org/library

2. Evaluations must be completed online by February 28,2014. Upon completion of the evaluation, a certificate for 1.0contact hour(s) may be printed.

Fees

ObjectivesThe purpose of this continuing nursing education article is toincrease the awareness of managing chest tubes in nurses and otherhealth care professionals. After studying the information presented inthis article, you will be able to:1. Discuss the use of chest tubes in patients on the medical-surgical

unit.2 Define pneumothorax and how it can be detected.3. Explain the differences between “wet” and “dry” chest drainage

units.4. Identify ways in which the medical-surgical nurse should assess

patients with chest tubes, as well as how to care for them.

Note: The author, editor, and education director reported noactual or potential conflict of interest in relation to this contin-uing nursing education article.

This educational activity has been co-provided by AMSN and AnthonyJ. Jannetti, Inc. Anthony J. Jannetti, Inc. is a provider approved by theCalifornia Board of Registered Nurses, provider number CEP 5387.Licensees in the state of CA must retain this certificate for four years afterthe CNE activity is completed.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nurs-ing education by the American Nurses’ Credentialing Center’s Commissionon Accreditation (ANCC-COA).

This article was reviewed and formatted for contact hour credit byRosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director.Accreditation status does not imply endorsement by the provider or ANCCof any commercial product.

Member FREE

Regular $20

CNECONTINUING

NURSINGEDUCATIONFree CNEto AMSN Members!

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866-877-2676 Volume 21 – Number 1

MSNCB Board of Directors Changes

On September 8, 2011, while at the AMSN Annual Conventionin Boston, MA, the MSNCB Board of Directors made severalchanges. They welcomed two new members, said goodbye to fellowcolleagues, and celebrated two current members filling new roles.Jane Kearns, MLS, has been appointed the new Public Member ofthe board. Carlo Piraino, Jr., MSN, RN, CMSRN, NE-BC, also cameon as Director. He is the Associate Chief of Nursing at the SouthTexas Veterans Health Care System in Kerrville, TX, and was previ-ously a navy nurse for 17 years. Both he and Jane were appointedfor 3 years. Congratulations, Jane and Carlo.

It is with regret that the board said goodbye to two direc-tors. Kathleen I. Marchiondo, MSN, RN, CMSRN, was a Directorsince 2008. She also served as Treasurer since 2009. MarthaHennessey, MPH, was the Public Member Director since 2006and served as Secretary since 2008. The MSNCB board will missthe distinctive contributions offered during discussions fromthese directors. The board wishes them the best in all of theirfuture endeavors.

To fill the officer slots, the following directors wereappointed:

Secretary: Patricia A. Kurz, MPS, CMSRN, NE-BCTreasurer: Mimi Haskins, MS, RN, CMSRN

The board thanks them for taking on these responsibilities.

CertificationQ: When will I receive the results of the exam?

A: If you take the paper and pencil exam, you will receiveyour results by mail approximately 8 weeks after the examdate. For computer-based testing, your exam will be scoredimmediately and you will receive your results after yourexam.

RecertificationQ: I have more than enough contact hours. Should I list all ofthem on my application?

A: Many nurses have more than the required 90 contacthours. Some have upwards of 200! It is permissible and evenadvisable to record more than 90 contact hours. This way, ifan activity needs to be moved from medical-surgical contentto professional development content, or if it needs to beremoved altogether, there will be more ready to fill the gap.However, if you are documenting more than 90 contacthours, consider sending no more than 20 extra.

Contact MSNCB at msncb@ajj.com or 866-877-2676 with your questions.

CMSRN (Certified Medical-Surgical Registered Nurse)certification is a rewarding endeavor that reflects specializedknowledge in medical-surgical nursing practice. Here are some ofthe most common questions about certification and their answers.

Frequently AskedQuestions

about

Hill-Rom is a leading manufacturer and provider of medicaltechnologies and services for the healthcare industry, includingpatient support systems, non-invasive therapeutic products, medicalequipment rentals, and information technology solutions.

CorporateSpotlight

Pictured (l-r): Carlo Piraino, Jr., Patrica A. Kurz, Karen Gregg, Sandy Fights, MimiHaskins, and Cynthia Ward. Not shown: Jane Kearns.

AMSN Supports its Members’ Pursuits

As a member, you are eligible to apply for one of several grantsand scholarships for professional development. AMSN awardedover $35,000 to its members last year. Take advantage of this mem-ber benefit to help you earn a higher degree, fund your research,offset the cost of certification, or get to the AMSN AnnualConvention. Many of these grants and scholarships are open nowor are soon to open. Visit the Scholarships & Grants section ofwww.amsn.org for the full list and eligibility.

Dealing with Difficult PeopleBy Managing Hot Buttons

Nurses must function in situations that can be highly emotionallycharged. As a result, the work environment is often perceived asdealing with difficult people*, leaving one feeling stressed, drained,and burned out. The key to taking care of one’s own emotionalneeds is to take charge of one’s reactions. By understanding howdifficult behaviors trigger hot buttons, nurses can learn to chooseresponses that neutralize negativity, reduce personal stress, andproduce a more positive work environment.

People exhibit behaviors that are difficult in all work environ-ments, but perhaps none more so than for nurses. On any given day,nurses are confronted by challenging patients and their families,demanding hospital personnel, and problematic team members.While training and experience prepare a nurse for this type of pres-sure cooker, over time the impact of this environment can leavenurses feeling frustrated, manipulated, or controlled, diminishingtheir capacity to handle problematic behaviors.

Why is this? It is because of the way the brain is wired. Whena nurse encounters a behavior perceived as difficult, the brain reg-isters this behavior as a threat and goes on high alert (Rock, 2009).For example, a combative surgeon can threaten one’s sense of secu-rity, resulting in anxiety or confusion; a judgmental peer may pro-duce feelings of doubt; a sarcastic administrator could leave onefeeling agitated. In each of these examples, a “hot button” has beenpushed. A hot button is a personal trigger that sends the individ-ual’s emotions plummeting in a negative direction. A nurse is not atliberty to prevent the detonation; however, the nurse is at liberty tochoose how to respond to that detonation. It is this choice thatdetermines subsequent feelings – increased stress and agitation orcalmness and well-being.

Amygdala HijacksNot all difficult behaviors are experienced as threats. For

example, one nurse may be very adept at dealing with angry familymembers. These situations rarely leave this nurse rattled. Yetanother nurse may encounter this same circumstance and perceiveit as intimidating and threatening; this nurse’s hot button is pushed,and negative feelings occur. What accounts for the difference inthese two responses? The answer lies with the amygdala, an almond-shaped cluster of interconnected structures in the emotional cen-ter of the brain, the limbic region. The amygdala stores emotionalmemory, much of which is based on early childhood experiences(Goleman, 1995). Incoming signals from the senses let the amygdala

scan every experience for trouble. Goleman (1995) stated if theamygdala perceives a threat based on its stored emotional memory,it “reacts instantaneously, like a neural tripwire, telegraphing a mes-sage of crisis to all parts of the brain….The amygdala’s extensiveweb of neural connections allows it, during an emotional emer-gency, to capture and drive much of the rest of the brain – includ-ing the rational mind” (pp. 16-17).

In other words, the neocortex, or rational part of the brain, hasbeen hijacked by the amygdala. Once the amygdala is activated, theindividual will have a knee-jerk reaction. The nurse is now emotion-ally flooded, with little access to rationale and reason. This processhappens within nanoseconds, and the hijack produces responsescharacterized by distorted perceptions, invalidation, defensiveness,and biased judgment. It also leads to the fight-flight response.

Managing Your Hot ButtonsThe key to dealing with difficult people is to shift one’s focus

from others’ behaviors, over which one has no control, to one’sown responses, over which there is total control. To understandwhy, let us again examine the way the brain functions. Once threat-ened, the brain starts searching for a sense of control and auton-omy. The brain detects that the individual is back in charge when itsenses the ability to make a choice. What matters most to the brainis the perception of choice (Rock, 2009.) In other words, a nurse whohas been hijacked by the amygdala doesn’t have to involve the diffi-cult person in his or her choices. The nurse just has to find a wayto let the brain know that there are choices to be made.

One simple method that deactivates the amygdala is puttingfeelings into words. Researchers found, for example, that when peo-ple attached the word sad to a sad-looking face, the amygdalaresponse decreased and the right ventrolateral prefrontal cortexresponse increased. This is the part of the brain that controlsimpulses (Lieberman et al., 2007). In practical terms, when a nurse’shot button has been pushed, the nurse can simply acknowledge thefeeling: “This is anxiety.” “This is fear.” And then the nurse can makea choice by asking, “How do I choose to handle this?” In this way, thenurse has decreased the brain activity that leads to automatic stressresponses and tapped into the brain area responsible for self-control and logic.

Rock (2009) described another strategy for regaining a senseof control:

I decide to be responsible for my mental state instead ofbeing a victim to circumstances. In the instant that I make thisdecision, I start seeing more information around me, and I canperceive opportunities for feeling happier. This experience is oneof finding a choice and making that choice, and it shifts what andhow I perceive in that moment. The idea of consciously choosingto see a situation differently is called reappraisal (p. 126).

How can a nurse use reappraisal to manage hot button reac-tions? One technique is to find a way of interpreting the facts thatlessen the threat. For example, by keeping in mind that frightenedpatients are more often than not feeling hijacked themselves, anurse might describe an overbearing patient as “hijacked” rather

www.amsn.org

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HealthyWORK ENVIRONMENTS

*The premise of this article is that people exhibit behaviors that are perceived by others as difficult. The term difficult people is used to simplify the discussion,but is not meant as a label or to imply that an individual is inherently difficult. In addition, behavior that is abusive, illegal, or unethical requires professional assis-tance and is outside the scope of this material.

than as “insufferable,” an interpretation that diminishes the nurse’sown hot button trigger.

Another technique is to recognize that one is not alone in areaction to certain difficult individuals. This process of normalizingdiminishes the brain’s threat arousal. A third reappraisal tactic is tolook at an event from another’s perspective. Consider this situation.A nurse has a work style that is task-oriented and likes to get a jobcompleted as quickly as possible. Another nurse likes to build rela-tionships by chatting before focusing on the task. The task-orientednurse becomes frustrated and angry listening to a colleague“schmooze.” To lessen the anger response, the nurse can choose tosee the situation through the eyes of the colleague, reappraising theinitial reaction that the peer is stalling and instead interpret the col-league’s behavior as meeting a need for comfort by talking. This typeof reappraisal works well for differences in work styles, values, useof time, and cultural backgrounds.

A fourth strategy to manage hot button reactions comes fromthe work of Fredrickson (2009) whose research demonstrates thatnegative emotions tend to linger in one’s mind. In other words, oncethe amygdala is activated, the end result is not only negative feelings,but also a negative mood. To curtail the impact of negative emo-tions, Fredrickson suggests deliberately choosing to counteract neg-ative emotions with positive ones. For example, a hijacked nursemight take a moment to think of a happy time, picture a loved one,or remember a pleasurable event. By choosing to replace negativefeelings with positive ones, a nurse is back in the control zone.

ConclusionNurses work in environments rife with difficult behaviors.

Patients and families are in altered states of fear and confusion,overtaxed colleagues may be in foul moods, and physicians can berude and demanding. While most nurses intellectually understandthe reason for these over-the-top behaviors, one too many difficultencounters can push a nurse’s hot button. By choosing to be“response-able” (able to choose one’s own responses) a nursebecomes empowered. By choosing to stop focusing on another’sbehavior and instead shift attention to one’s own responses, a nursecan experience enormous relief and personal well-being.

ReferencesFredrickson, B.L. (2009). Positivity: Groundbreaking research reveals how to

embrace the hidden strength of positive emotions, overcome negativity, andthrive. New York: Crown.

Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ.New York: Bantam Books.

Lieberman, M.D., Eisenberger, N.I., Crockett, M.J., Tom, S.M., Pfeifer, J.H., &Way, B.M. (2007). Putting feelings into words: Affect labeling disruptsamygdala activity to affective stimuli. Psychological Science, 18(5), 421-428.

Rock, D. (2009). Your brain at work: Strategies for overcoming distraction, regain-ing focus, and working smarter all day long. New York: HarperCollins.

Dana Lightman, PhD, is an expert in positive psychology, andthe creator of POWER Optimism, Abington, PA. She is the authorof the “No More Difficult People” series.

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Susan GrossBarbara J. LarsenJennifer A. MolloDonna PilonTracey Silfies

Lehigh Valley Health Network (LVHN)is a 988-bed academic, community Magnet®

designated health network located inNortheastern Pennsylvania. In 2006, a 32-bed orthopedic floor at this Level I TraumaCenter noted an increase in pressure ulcersand developed a unit-based Skin IntegrityCommittee that was instrumental in chang-ing practices hospital-wide through the useof evidence-based practice.

In 2008, Medicare implementedchanges regarding reimbursement for pres-sure ulcers (PUs) acquired in the healthcare setting (Institute for HealthcareImprovement [IHI], 2007). The fiscal implica-tions in combination with further emphasison improving patient outcomes promptedthe committee, in conjunction with nursingleadership on the orthopedic unit, to inves-tigate and implement additional strategiesto significantly impact reduction of pressureulcers in the medical-surgical population.The theme, Back to Basics, guided imple-mentation strategies for the orthopedicunit staff to achieve and sustain outcomessurrounding pressure ulcer reduction.

Back to Basics: First StepsThe Skin Integrity Committee was cre-

ated due to an increase from five hospital-acquired pressure ulcers reported in 2005to 34 reported pressure ulcers developedgreater than 24 hours after admission in2006. Members of this multidisciplinarycommittee included experienced orthope-dic registered nurses (RNs), unlicensedassistive personnel (UAP), unit nursemangers, the orthopedic unit-based educa-tor, nursing director, and a wound, ostomy,continence (WOC) nurse. The committee’sinitial step was to review the current stateof the staff’s pressure ulcer preventionmethods.

After the review, the committeedecided to utilize case scenarios for RNs toevaluate their baseline knowledge of skin

assessment, documentation skills related topressure ulcers, descriptions and staging ofpressure ulcers, and developing a plan ofcare. In addition, a baseline evaluation ofunlicensed staff was established regardingtheir role with pressure ulcer prevention.All staff, licensed and unlicensed, wererequired to complete the evaluation. Thebaseline evaluation revealed the following:incorrect and/or inconsistent staging ofpressure ulcers, documentation omitted ordone incorrectly, and unfamiliarity withproper use of some prevention products,such as creams and under pads.

Secondly, the Skin Integrity Committeecompleted a review of evidence associatedwith the use of draw sheets and under pads.It was found that under pads without wickability inhibit a moisture-free area and padfolds substantially raise peak pressure ridgesfor patients on specialty beds (Duncan,2007; Fader, Bain, & Cottenden, 2004;Gibbons, Shanks, Kleinhelter, & Jones, 2006;IHI, 2007). The use of under pads should bereserved for those patients with grossincontinence or draining wounds (IHI,2007).

Current practice on the orthopedicunit was to place non-absorbent under padson all patient beds. Based on the evidence,

the committee trialed the use of drawsheets on all patient beds to reduce friction,as these were readily available on the unit ata low cost and are much thinner than underpads. The committee rolled out educationto all staff on the orthopedic unit regardingproper utilization of draw sheets, includingsmoothing the sheet out to eliminate wrin-kles, and stressed that under pads were onlyto be used for grossly incontinent patientsor patients with draining wounds. Thisresulted in a 10% decrease in the rate ofnew pressure ulcers greater than 24 hoursafter admission over a 12-month period.Due to these outstanding results, this sim-ple, effective strategy to prevent pressureulcers has been implemented network-wide.

Sustaining the PositiveMomentum

The above changes resulted in improv-ing patient care in the acute care settingwhile decreasing costs associated withtreatment of pressure ulcers. But they werejust the beginning of the staff’s Back toBasics journey regarding pressure ulcer pre-vention and progression for staff. The fol-lowing are additional strategies utilized:• Collaboration with wound care special-

Back to Basics: A Medical-Surgical Orthopedic Unit’s Quest to Decrease Pressure Ulcers

Licensed Staff Unlicensed Staff

Case Scenarios:• Pressure ulcer staging• Appropriate interventions — under pads vs.

draw sheets; use of waffle chair cushions

“Jeopardy” style questions to establish baselineknowledge:• Specialty beds, such as pressure distribution

mattresses • Skin products, such as Proshield®

• Repositioning• Bathing

National Database of Nursing Quality Indicators(NDNQI): • Pressure ulcer training modules online

Skin integrity quiz:• Under pads vs. draw sheets• Use of waffle chair cushions

Wound, Ostomy, and Continence NurseEducation:• Skin products, such as Proshield®

• Pressure ulcer staging

Management rounds:• Ensure interventions by unlicensed staff were

appropriate• Answer any questions

Table 1.Back to Basics Education for Staff on the Orthopedic Unit

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ists on a daily basis to assure accuracyof staging and documentation of pres-sure ulcers

• Education regarding levels of mobilityand repositioning of at-risk patients forall staff utilizing case studies, modules oneLearning (electronic learning manage-ment system), and one-on-one educa-tion (see Table 1)

• Implementation of wound charts (seeFigure 1) and a revised Kardex toimprove documentation, communica-tion, and efficiency among staff mem-bers

• Procurement of a specialty bed, such asa pressure distribution mattress, for

the Braden Score® (Bergstrom,Demuth, & Braden, 1987): The BradenScale® (see Table 2) has been incorpo-rated into the unit’s revised Kardex, aswell as the electronic documentationsystem. This has led to more accurateskin assessments and prevention ofpressure ulcers.

• Nursing leadership continues to pro-vide education as necessary to assureall nurses accurately complete skinassessments

ResultsFigure 2 illustrates pressure ulcer rates

on the medical-surgical orthopedic unitfrom 2006 to the present. Since implemen-tation of the Back to Basics strategies in2008, there has been a significant decreasein pressure ulcers developed greater than24 hours after admission. Despite a slightincrease in 2009, this trend has continued,yielding a 15% decrease in 2010.

Next StepsAs staff continues to make progress

toward effective pressure ulcer preventionoutcomes, they again turn to evidence-based research for the newest and mosteffective initiatives. The following representsonly a small portion of additional ideas forthe reduction of skin breakdown:• Head of bed at 30-45 degrees to reduce

shearing and friction forces (Griffin,Cooper, Horack, Klyber, &Schimmelpfenning, 2007)

• Education for specific departments (ED,OR, PACU) to communicate positionand duration of procedure during hand-off report (Griffin et al., 2007)

• Natural products, such as honey, to pro-mote tissue healing in Stage I and StageII pressure ulcers (Simon et al., 2009;Yapucu-Güneş & Eşer, 2007)

• Incentives for staff members to reassessand implement interventions (Barry,Brannon, & Mor, 2005)

• Specific labs such as albumin, pre-albumin, transferrin, and a completeblood count to assess the nutritionalstatus of at-risk patients (Bluestein &Javaheri, 2008)

• Platelet derived growth factor toenhance healing capabilities (Bluestein &Javaheri, 2008)

patients with Stage III or Stage IV pres-sure ulcers

• Use of soft chair waffle cushions for allorthopedic patients

• Education, both verbal and written, wasprovided to patients and families on thenecessity of changing position or shift-ing body weight on a regular basis inorder to redistribute pressure

• Use of towel rolls, pillows, and heellifters to decrease risk of skin break-down when in bed

• Re-validation utilizing case scenarios,emails, signage reminders, and one-on-one education occurred to ensure staffunderstood and properly documented

Figure 1.Anatomical Man Utilized for Comprehensive Documentation of Pressure

Ulcers and/or Wounds, Part of Revised Nursing Kardex

Source: Reprinted with permission from ConvaTec©, Solutions Algorithms for Wound Care, AP-004782-US.

RIGHT LEFT LEFT RIGHT

RIGHT FOOT RIGHT LEFT LEFT FOOT

continued on page 19

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Criteria Name Criteria Definition Criteria Labels

SensoryPerception

Ability to respondmeaningfully topressure-relateddiscomfort

1. Completely Limited: Patient is unresponsive topainful stimuli, due todiminished level ofconsciousness or sedation;OR Patient has limited abilityto feel pain over most of bodysurface.

2. Very Limited:Patient responds only topainful stimuli, cannotcommunicate discomfortexcept by moaning orrestlessness; OR Patient hassensory impairment, whichlimits the ability to feel pain ordiscomfort over 1/2 of body.

3. Slightly Limited:Patient responds to verbalcommands but cannotalways communicatediscomfort or need to beturned; OR Patient has somesensory impairment whichlimits the ability to feel painor discomfort in 1 or 2extremities.

4. No Impairment:Patient responds to verbalcommands and has nosensory deficit, which wouldlimit ability to feel or voicepain or discomfort.

Moisture Degree to whichskin is exposedto moisture

1. Constantly Moist:Skin is kept moist almostconstantly by perspiration,urine etc. Dampness isdetected every time patient ismoved or turned.

2. Moist:Skin is often but not alwaysmoist. Linen must bechanged at least once a shift.

3. Occasionally Moist:Skin is occasionally moist,requiring an extra linenchange approximately once aday.

4. Rarely Moist:Skin is usually dry Linenrequires changing only atroutine intervals.

Activity Degree tophysical activity

1. Bedfast:Confined to Bed

2. Chairfast:Ability to walk severelylimited or nonexistent. Cannotbear own weight and/or beassisted into chair orwheelchair.

3. Walks Occasionally:Walks occasionally duringday but for very shortdistances, with or withoutassistance. Spends majorityof each shift in bed or chair.

4. Walks Frequently:Walks outside the room atleast twice a day and insideroom at least once every 2hours during waking hours.

Mobility Ability to changeand control bodyposition

1. Completely Immobile:Patient does not make evenslight changes in body orextremity position withoutassistance.

2. Very Limited:Patient makes occasionalslight changes in body orextremity position but unableto make frequent orsignificant changes.

3. Slightly Limited:Patient makes frequentthough slight changes inbody or extremity positionindependently.

4. No Limitations:Patient makes major andfrequent changes in positionwithout assistance.

Nutrition Usual food intakepattern

1. Very Poor:Patient never eats a completemeal. Patient rarely eats morethan 1/3 of any food offered.Patient eats 2 servings or lessof protein (meat/dairy) perday. Patient takes fluids poorly& does not take a liquiddietary supplement; ORPatient is *NPO and/ormaintained on clear liquids or**IV for more than 5 days.

2. Probably Inadequate:Patient rarely eats a completemeal and generally eats onlyabout 1/2 of any food offered.Protein intake includes only 3servings (meat/dairy) per day.Occasionally will take adietary supplement; ORPatient receives less thanoptimum amount of liquiddiet or tube feeding.

3. Adequate:Patient eats over half of mostmeals and a total of 4servings of protein each day.Patient occasionally willrefuse a meal, but will usuallytake a supplement if offered;OR Patient is on a tubefeeding or ***TPN regimen,which probably meets mostof nutritional needs.

4. Excellent:Patient eats most of everymeal and never refuses ameal. Patient usually eats atotal of 4 or more servings ofprotein a day andoccasionally eats betweenmeals. Does not requiresupplementation.

Friction/Shear 1. Problem:Patient requires moderate tomaximum assistance inmoving. Complete liftingwithout sliding against sheetsis impossible. Patientfrequently slides down bed orchair, requiring frequentrepositioning with maximumassistance. Spasticity,contractures, or agitationleads to almost constantfriction.

2. Potential Problem:Patient moves feebly orrequires minimumassistance. During a move,skin probably slides to someextent against sheets, chair,restraints, or other devices.Patient maintains relativelygood position in chair or bedmost of the time butoccasionally slides down.

3. No Apparent Problem:Patient moves in bed and in chair independently and hassufficient muscle strength to lift up completely during move.Maintains good position in bed or chair at all times.

Table 2.Braden® Scale for Predicting Pressure Ulcer Risk Utilized on the Orthopedic Unit at LVHN:

Critical Indicators AssessmentRISK SCORE

Very High Risk: Total Score < 9; High Risk: Total Score 10 – 12; Moderate Risk: Total Score 13 – 14;Low Risk: Total Score 15 – 16 if under 75 years old OR 15 – 18 if over 75 years old

*NPO – Nothing by Mouth; **IV – Intravenously; **TPN – Total parenteral nutrition; Source: Reprinted with permission from Braden & Bergstrom©, 1988.

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ConclusionMedicare continues to set the bar for

what is considered reimbursable regardinghospital-acquired pressure ulcers. The SkinIntegrity Committee on a medical-surgicalorthopedic unit at a Magnet® health net-work maintains a focus on inexpensive, effi-cient, and easy to implement interventionsto prevent skin breakdown. The Back toBasics strategies have been implementedthroughout the network due to the successof the program on the medical-surgicalorthopedic unit.

ReferencesBarry, T.T., Brannon, D., & Mor, V. (2005). Nurse

aide empowerment strategies and staff sta-bility: Effects on nursing home resident out-comes. Gerontologist, 45(3), 309-317.

Bergstrom, N., Demuth, P.J., & Braden, B.J. (1987).A clinical trial of the Braden Scale for pre-dicting pressure sore risk. Nursing Clinics ofNorth America, 22(2), 417-428.

Bluestein, D., & Javaheri, A. (2008). Pressureulcers: Prevention, evaluation and manage-ment. American Family Physician, 78(10),1186-1194.

Duncan, K.D. (2007). Preventing pressure ulcers:The goal is zero. Joint Commission Journal on

Quality and Patient Safety, 33(10), 605-610.Fader, M., Bain, D., & Cottenden, A. (2004). Effects

of absorbent incontinence pads on pres-sure management mattresses. Journal ofAdvanced Nursing, 48(6), 569-574.

Gibbons, W., Shanks, H.T., Kleinhelter, P., & Jones,P. (2006). Eliminating facility acquired pres-sure ulcers at Ascension Health. JointCommission Journal on Quality and PatientSafety, 32(9), 488-496.

Griffin, B., Cooper, H., Horack, C., Klyber, M., &Schimmelpfenning, D. (2007). Best-practiceprotocols: Reducing harm from pressureulcers. Nursing Management, 38(9), 29-31, 69.

Institute for Healthcare Improvement (IHI).(2007). Protecting 5 million lives from harm.Retrieved from http://www.ihi.org/IHI/Programs/Campaign

Simon, A., Traynor, K., Santos, K., Blaser, G., Bode,U., & Molan, P. (2009). Medical honey forwound care – Still the ‘latest resort’?Evidence-Based Complementary andAlternative Medicine: eCAM, 6(2), 165-173.

Yapucu-Güneş, U., & Eşer, I. (2007). Effectivenessof a honey dressing for healing pressureulcers. Journal of Wound, Ostomy, andContinence Nursing, 34(2), 184-190.

Susan Gross, BSN, RN, is a Patient CareCoordinator, Lehigh Valley Health Network,Allentown, PA.Barbara J. Larsen, BSN, RN, ONC, is aStaff Nurse, Lehigh Valley Health Network,Allentown, PA.Jennifer A. Mollo, BSN, RN, is a StaffNurse, Lehigh Valley Health Network,Allentown, PA.Donna Pilon, RN, is a Staff Nurse, LehighValley Health Network, Allentown, PA.Tracey Silfies, BSN, RN, CMSRN, is aPatient Care Specialist, Lehigh Valley HealthNetwork, Allentown, PA.

0

5

10

15

20

25

30

35

40

2006 2007 2008 2009 2010

New PU > 24hrs after admission PU - admitted from other facility PU - patients home — — Unit-based PU

Figure 2.Rate of Pressure Ulcers on Medical-Surgical Orthopedic Unit,

2006 to 2010 (Calendar Year)

Figure 2 illustrates that since implementation of the Back to Basics strategies in 2008, there has beena significant decrease in the incidence of pressure ulcers (PUs) developed greater than 24 hours afteradmission. In 2009, the unit experienced an increase in PUs due to staff not adhering to the Back toBasics prevention strategies implemented in 2008. The staff were re-educated on these simple strate-gies and the importance of skin integrity again became a focus on the unit. The re-education proved tobe effective and despite the slight increase in 2009, the positive trend continued, yielding a 15%decrease in PUs in 2010.

AMSN Scholarships & Grants Program

Thanks to our members, AMSN awards dozens of nurses withresearch grants, scholarships, and awards every year through theScholarships, Grants, and Awards program. Members support their spe-cialty when they donate to this important program. To help, indicate adonation amount on your membership renewal or go to www.amsn.organd click on the Donation Form under the Scholarships & Grants section.

Are you one of our members whose career has been advancedthrough this? We’d like to hear your story! Send your experience toamsn@ajj.com.

Chapter Events

www.amsn.org

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ChapterNEWS

AMSN members walking for the Alzheimer’s Association included: DawnBardygula, Fortune Dabu, Mary Sue Dailey, Michelle Duke, Gail Gotsis, DianeKuenhlenz, Joanne LaMantia Watts, Kandice Vancura, Susan Thompson, and LeahWoodcock.

Chicago Suburban Chapter #323

The Chicago Suburban Chapter #323 recruited participantsand monetary donations to support the Alzheimer’s Association inthe Walk to End Alzheimer’s on Sunday, September 25, 2011.Members and their friends and families joined together to raiseover $1,800 to help support this mission. The chapter exceeded itsgoal in donations and participants.

For more information about the Chicago Suburban Chapter,contact Susan Thompson at susan.thompson@advocatehealth.com.

North Georgia Chapter #236

The North GeorgiaChapter held a meeting onSeptember 15, 2011. TinaJordan, RN, and Mary AnnGaddis, RN, presented agreat program about hospi-tal care for the morbidlyobese patient. Several nurs-ing students from 2 localuniversities attended, as didseveral nurses from the hospital. This program awarded 1 hour ofcontinuing nursing education credit.

For more information about the North Georgia Chapter, con-tact Dot Pardue at dot.pardue@nghs.com.

Central Indiana Chapter #304

The fourth annual “Med-Surg Bowl,” sponsored by the CentralIndiana Chapter of AMSN, was held November 1, 2011, at IU HealthMethodist in Indianapolis. The event is held every year during Med-Surg Nurses Week in November. The three previous Med-SurgBowls had teams from four different area hospitals competing. Themost recent event blossomed into nine hospitals participating:Community, Franciscan St. Francis, Hendricks Regional, IU HealthBall Memorial, IU Health Methodist, IU Health University, Richard L.Roudebush VA Medical Center, St. Vincent, and Wishard Hospital.

The Med-Surg Bowl is a Jeopardy-style game where bedsidenurses who work on med-surg units compete against their col-leagues from other hospitals. Topics included: Assessment/Signs andSymptoms, Anatomy, Labs, Blood, Spelling, Abbreviations, and many,many more. Seven games were played in an elimination fashion. TheFinal Round was a neck-and-neck, with the team from Richard L.Roudebush VA Medical Center narrowly defeating the team fromHendricks Regional Hospital.

AMSN Chapter Officers are already working on planning theNovember 2012 event. Any Chapters wishing to start a “Med-SurgBowl” in their area can contact Karen Gregg at Karen.Gregg@Franciscanalliance.org for information on how to get started. Formore information about the Central Indiana Chapter, contact presi-dent Monica Magna at monicamagna63@yahoo.com.

Team members from Richard L. Roudebush VA Medical Center won the 2011Med-Surg Bowl, sponsored by the Central Indiana Chapter of AMSN.

Tina Jordan and Mary Ann Gaddis

received a certificate of recognition, a $50 check, and two compli-mentary 1-year AMSN memberships to take home to her chapter.Pat: Congratulations on being recognized for the educationalopportunities that your chapter held. Your report listed six events,including four events that were daylong, awarding 6-7 CNE contacthours. Can you tell me how this is done?Barbara: We have a steering committee, which is composed oftwelve members from eight different hospitals. These are nurses inleadership positions in medical-surgical nursing within theDallas/Fort Worth area. This group is very cohesive and can bedescribed as being a “Pool of Talent.” The officers from the chapterwork closely with this steering committee. This committee meets 9-10 times each year. The meetings are open to all members.For 2010-2011, we were able to offer two 2-day med-surg certifica-tion review prep courses. In September, 30 nurses were in atten-dance. For the two other events, we had multiple presenters for thedaylong programs with 78 and 38 nurses in attendance. Our mem-bers have expressed a desire for all-day programs. By having these,we have good evaluations and improved program attendance.Pat: Do you have difficulty finding speakers/presenters for theseevents?Barbara:The steering committee is aware of local experts. If thetiming is agreeable, they are very willing to share their expertise andgive of their time to the med-surg nursing community.Pat: Tell me about your officers and the structure of your leader-ship team.Barbara:The president and the secretary are elected in the sameyear and they serve a two-year term. Our current secretary is TessMagalong, and she and I are in office from 2010-2012. The treasureralso holds a two-year position and is elected in a different year.Carolyn Schaefer is the treasurer. At this time, the president-electposition is yet to be determined.Pat: I see that your membership comes from over 40 different facil-ities. How are you able to attract so many members and what is yourcurrent membership?Barbara: Our chapter was chartered in 2005. When we submit-ted our annual report in June 2011, we had 35 members. We nowhave 82 members. Our members come from a 30-mile radius to ourevents. The events are held in various facilities within that 30-milearea. We request input from our members concerning topics ofinterest.Pat:What exciting activities are in the planning stage for your chap-ter?Barbara: We hope to offer another 2-day certification reviewcourse this year. We also plan to offer our 5th Annual Med-SurgSymposium in the spring. A topic that is being considered is “Nursingthe Nurse: Heart, Mind, and Soul.”Pat: Thank you for your time and sharing strategies used by yourchapter. I hope this information can help other chapters as they planfor their educational activities. I see that your chapter lives theAMSN Strategic Message: The professional and personal devel-opment of nurses. Keep up the great work in North Texas!

Patricia Smart, RN-BC, MN, CNEProfessor of Nursing

Chair, AMSN Chapter Development Committee

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866-877-2676 Volume 21 – Number 1

North Texas Chapter #205Recognized for Educational

OpportunitiesAs chair of the Chapter Development Committee, I have

decided to highlight a chapter in each issue of MedSurg Matters! Inthe last issue, Chicago Chapter #317 was highlighted, since it was therecipient of 2011 Chapter of the Year Award.

I am aware of the time and effort it takes to be in a leadershiprole for a local chapter. I was the president of Deep South Chapter#218 from 2009-2010. This office is a three-year commitment – oneyear as president-elect, one year as president, and one year as pastpresident. I commend all presidents and officers for local chapters.Even though leadership takes extra time and energy, I feel that I grewprofessionally during those three years. This time also gave me theexperience and confidence to pursue additional offices in otherlocal, state, and national professional nursing organizations.

I am hoping that by sharing the story of the chapters and pres-idents that were recognized at the 2011 AMSN Annual Convention,other chapters can receive ideas and strategies to grow. I was ableto recently complete a telephone interview with Barbara Warren,the president of the North Texas Chapter #205. Barbara and I hadmet during The Chapter Award Breakfast during the convention inBoston. This chapter was recognized for its superior efforts inEducational Opportunities. During the Award Ceremony, Barbara

New ChapterCentral Missouri Chapter #326

Congratulations to the Central Missouri chapter, which earnedits charter in October 2011. Serving Columbia/Jefferson City, thechapter has appointed the following officers:

President . . . . . . . . . . . . . . . Lori MannPresident-Elect . . . . . . . . . . Mary WilliamsonSecretary . . . . . . . . . . . . . . . Stacy SkeensTreasurer. . . . . . . . . . . . . . . Melissa Dowler

Other committees are Educational, Fundraising, andMembership Recruitment. The chapter reaches out to seven facili-ties. The goal of the chapter is to start and increase membership byexpanding to other facilities. The chapter will meet in February,August, and November at rotating locations. For more information,contact president Lori Mann at CentralMissouriAMSN@gmail.com.

Front row (l-r): Caroline Barrera (Committee Fundraising Chair) and Stacy Skeens(Secretary). Back row (l-r): Lynn Wheeler (Membership Committee Chair), MelissaDowler (Treasurer), Mary Williamson (President-Elect), and Lori Mann (President).

Academy of Medical-Surgical Nurses www.amsn.org

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Diane Daddario, Cindy Ludwig, and Terry Ditton represented AMSN andMSNCB in the exhibit hall at the ANCC Magnet Conference in Baltimore,MD, October 4-6, 2011.

ANCC Magnet ConferenceIt is very important for AMSN members to exercise their mem-

bership benefit of voting for the Board of Directors. In May, AMSNmembers will be asked to select two candidates to serve as Directoron the National Board of Directors and one candidate as Treasurerfor a term of office of October 2012 through October 2015.

“But I don’t know the candidates.” As requested, AMSN ishelping members be more informed. Members will receive a link viaemail to access each candidate’s biography a month before we send theballot. We will also have a description of the role of Director andTreasurer posted on our Web site (www.amsn.org). The membershipwill have time to review the candidates and make an educated decision.

AMSN uses electronic voting for national elections. Nurses areprofessionals on the go and e-voting gives maximum access to eachAMSN member. On May 1, members will receive an email messagefrom the AMSN Election Coordinator, AMSNvote@directvote.net.To ensure you receive this important message, please add this addressto your contacts or safe-sender list today. The message will includeyour member number and passcode and a voting link. We requireyour current email address to send you a ballot. Please logininto www.amsn.org as soon as possible and edit your account to becertain we have your correct email address. You can also call us toll-free at 866-877-2676 and we’ll be happy to assist you. AMSN valuesyour privacy and will NOT give or sell your email address to others.

Look for instructions for casting your electronic ballot to arrivevia email on May 1.

AMSN is your specialty organization. Voice your opinion andvote for your future leaders!

Does AMSN have your current email address?Make sure we do so that you receive upcoming election infor-mation to be able to vote electronically.

Also, please add amsn@ajj.com to your email address book toensure emails from AMSN get to your inbox.

AMSN Corporate Members

Philips Healthcare3000 Minuteman Road

Mail Stop 375Andover, MA 01810

1-800-934-7372www.healthcare.philips.com/us

Your Vote ShapesThe Future of AMSN!

How You Can Help AMSN Benefit More Nurses

How can helping nurses benefit from AMSN also benefit you?(Other than being surrounded by dedicated nurses desiring toimprove med-surg health care, we mean.) For any new nurse whojoins AMSN because of your personal recommendation, we takenotice. If 5 nurses join due to your connection, we’ll give you a $25gift certificate. The more, the merrier (and richer you’ll be). If youinspire 10 fellow nurses to join AMSN, the reward doubles to $50.Help AMSN reach out and benefit more med-surg nurses andincrease your member benefits too! You can read more about theprogram at www.amsn.org in the Membership section.

Hill-Rom1069 State Route 46 EastBatesville, IN 47006-9167

1-800-445-3730www.hill-rom.com

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The official AMSN journal, MEDSURG Nursing, is a peer-reviewed journal that includes continuing nursing education,research, and articles that discuss best practices for the medical-surgical nurse. I can’t tell you how many times I am able to take anarticle from the journal to my classroom or the clinical unit to helpnurses learn and improve the quality of care provided to patients.

Lastly, Med-Surg Nursing Connection is an electronic newsletterthat provides a look at the hot topics affecting the practice of themedical-surgical nurse and news about AMSN activities.

Once I completed my master’s degree, my next step was tofind a way to demonstrate my expertise in my practice specialty. Iwanted to become certified in medical-surgical nursing. I work dili-gently to maintain my certification through continuing nursing edu-cation sessions provided at convention, in journal materials, andthrough practice activities. I was proud and excited when theMedical-Surgical Nursing Certification Board (MSNCB) was formedand the Certified Medical-Surgical Registered Nurse (CMSRN) cer-tification was born. I am proud to have been part of the originalitem-writing group for the certification exam. For me, becomingcertified as a medical-surgical nurse was one way to demonstrate acommitment to lifelong learning and excellence in practice. AMSNprovides a number of resources to assist nurses as they prepare forthe certification exam. The Certification Review Course On-The-Road program provides a live presentation in your facility. Manyother resources for certification can be found at www.amsn.org.

The AMSN Online Library provides another opportunity formembers to continue learning. I have found the Online Library ahuge help in maintaining the continuing nursing education contacthours needed for continued certification. Between home, AMSN,course work, and my job responsibilities, I need to be able to getcontinuing education credit when it fits my schedule. The OnlineLibrary is perfect for that. Members are eligible for at least 18Continuing Nursing Education contact hours each year – not at adiscount, but for free! The Online Library includes a wide variety oftopics to help you grow personally and professionally.

AMSN further assists members in their pursuit of personal andprofessional development by offering scholarships and grants toassist them in their certification journey, conduction of research, andin evidence-based practice studies. I am proud to say that in the lastyear $35,000 was awarded to AMSN members. I had the pleasure ofhearing some of the stories and testimonials of nurses who attendedconvention on a grant. Others have shared how a certification grantmade it possible for them to sit for the certification exam.

Members can increase their leadership skills by participating inthe committees and task forces of the association. Personally, myactivities in nursing organizations strengthened my abilities at work.Being a part of a task force helped me learn how to work withinthe group, how to access resources, and eventually how to lead agroup to the completion of a task. These are important skills for allmedical-surgical nurses whether, seeking a role in a nursing organi-zation or the practice setting or in providing the best care for ourpatients. More and more nurses are seeking this opportunity.Recently, there were more than 40 members that responded to acall to participate in a work group. That is amazing!

In addition to participating in committee or task force work,our members can build connections with other medical-surgicalnursing colleagues by attending the annual convention, which isknown for its high quality and excellence in educational offerings.Attending the convention is important as medical-surgical nursesseek to improve their practice and patient care. Members receiveregistration discounts for convention and are eligible to apply forscholarships toward convention registration and expenses.Convention presentations are also available in the AMSN OnlineLibrary free of charge for attendees to review as desired. These ses-sions are also available at a discounted fee to AMSN members.

With all AMSN has to offer, we need to get the message outso more of the 600,000 medical-surgical nurses can reap the bene-fits of AMSN membership. My challenge in 2012 is for everyAMSN member to recruit one new member. This wouldquickly double our numbers, add to AMSN resources and create agreater ability to serve medical-surgical nurses and advocate for ourspecialty.

When talking to your friends and colleagues, tell them whatAMSN means to you. Tell them what you gain by being a member.You know they are going to ask about the membership dues. Andyou know you are going to hear, “It’s too expensive. I can’t afford it.”The dues are $84 a year. I always try to see how a cost will impactthe monthly budget – $84 works out to $7 a month – 2 ‘lattes’ amonth. Better than that, it figures to 23 cents a day. You can reallyadd the guilt in saying, “Can’t you spend less than a quarter a day tobelong to your professional nursing organization?” I am shamelesswhen it comes to getting nurses involved! Seriously, that is cheaperthan a soft drink at lunch or coffee on the way to work. Not evena dollar a day! Just 23 cents! What a steal for all that AMSN offers!Make sure to give them a copy of the membership application (avail-able online) or simply refer them to the AMSN Web site.

Through the AMSN Member-Get-a-Member program, AMSNmembers who recruit five new members will receive a $25 gift cer-tificate for AMSN products and services. The recruiter’s name mustbe included in the referral section of the membership application.AMSN members are eligible to earn the award each year.

I realize in this message I am “preaching to the choir.” I amthankful for each member of AMSN. I am proud to be a medical-surgical nurse and to serve the AMSN membership as president. Mydream is for every medical-surgical nurse to reap the benefits ofAMSN. While AMSN diligently speaks for medical-surgical nurses, itis so much more than that. AMSN has so much to offer; let’s tellthe universe of medical-surgical nurses what they are missing. All ofus who have benefitted from AMSN membership are the bestrecruitment tool out there for building our membership. Pleaseaccept my challenge and encourage at least one of your medical-surgical colleagues to join AMSN. I think this is a great way toincrease the visibility of medical-surgical nursing as a specialty andto ultimately improve patient care.

ReferenceHealth Resources and Services Administration (HRSA). (2010). The regis-

tered nurse population: Findings from the 2008 national sample survey ofregistered nurses. Retrieved from http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf

Sandra D. Fights, MS, RN, CMSRN, CNEAMSN President

President’s Messagecontinued from page 2

MedSurg Matters! is indexed in the Cumulative Index to Nursing & Allied Health Literature.

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PAIDBellmawr, NJPERMIT #58

AJJ-0212-V-85C

The mission of AMSN is to promote excellence in medical-surgical nursing.

Enhance your CV by submitting a manuscript to MedSurg Matters! Visit http:// www.amsn.org/Newsletter for topic ideas and author guidelines.

East Holly Avenue, Box 56, Pitman, NJ 08071-0056 • 866-877-AMSN (2676)amsn@ajj.com • www.amsn.org

Volume 21 – Number 1 • January/February 2012

Please think GREEN and recycle!

We Are Who You AreAbout Your Demographic Profile

AMSN wants to know more about you through 10 simple demographic questions.Answering them helps you, the organization, and the specialty.

How will your completed profile benefit you?AMSN sends specific messages to our members who we believe will be interested in

the topic of the message. We use the demographic data you provide to determine therecipients of the message. For instance, when a position for a volunteer opens that matchesyour description, we can let you know about it.

How will it benefit AMSN?AMSN is you, the medical-surgical nurse. When you tell us how long you’ve been in

med-surg, what your position is, or what kind of care setting you work in, you’re puttingyour imprint on the composite of med-surg nurses. We better understand our member-ship profile and what resources to provide to you.

How will it benefit the specialty?When AMSN uses its unified voice to speak on behalf of the medical-surgical nursing

specialty, we can accurately reflect who this group of nurses is, what we do, and where thefuture of our specialty is trending.

To update your demographics:1) Visit www.amsn.org and login to your account.2) Click the Edit link above your name on the Individual Information page.3) Click the gray Manage Demographics box (near your email address). Complete or

change the information and click Save.

AMSN BOARD OF DIRECTORS

PresidentSandra D. Fights, MS, RN, CMSRN, CNE

President-ElectKathleen Lattavo, MSN, RN, CNS-MS, CMSRN,

RN-BC, ACNS-BC

TreasurerJill Arzouman, MS, RN, ACNS, BC, CMSRN

SecretaryRobin Hertel, MSN, RN, CMSRN

DirectorDee A. Eldardiri, MS, RN-BC, CMSRN

DirectorJane E. Lacovara, MSN, RN, CMSRN, CNS-BC

DirectorDenise Verosky, MS, ACNS-BC, CMSRN

DirectorLinda Yoder, PhD, MBA, RN, AOCN, FAAN

Executive DirectorCynthia Hnatiuk, EdD, RN, CAE

Director Association ServicesSuzanne Stott, BS

MedSurg Matters!

EditorJanet E. Burton, MSN, RN, CMSRN

Editorial CommitteeTracy D.B. Aniello, MSN, BSN

Tammeshin Frazier, BSN, RN, CMSRNBarbara Goldberg-Chamberlain, PhD, APRN, MBA, CCRN, WCC

Jennifer Kennedy, MSN, RNRon Ordona, MSN, RN, CMSRN

Sally S. Russell, MN, CMSRN, CPPColleen K. Smith, MSN, RN, CMSRN

Elizabeth Thomas, MSN, ACNS-BC

Managing EditorKatie R. Brownlow, ELS

Editorial CoordinatorJamie Kalitz

Graphic DesignerRobert Taylor

Education DirectorRosemarie Marmion, MSN, RN-BC, NE-BC

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