Wednesday, April 3, 2019

The Affordable Care Act

Oh wow. This is great! It is the best summary of the Affordable Care Act (ACA) purpose and intent that I have seen to date. It is from the article The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice by Sarah Rosenbaum, in the Public Health Reports journal Vol. 126 No. 1, published in 2011.

“Consisting of 10 separate legislative Titles, the Act has several major aims.

The first—and central—aim is to achieve near-universal coverage and to do so through shared responsibility among government, individuals, and employers.

A second aim is to improve the fairness, quality, and affordability of health insurance coverage.

A third aim is to improve health-care value, quality, and efficiency while reducing wasteful spending and making the health-care system more accountable to a diverse patient population.

A fourth aim is to strengthen primary health-care access while bringing about longer-term changes in the availability of primary and preventive health care.

A fifth and final aim is to make strategic investments in the public's health, through both an expansion of clinical preventive care and community investments.”

This is not what people understand, and there is just no way to educate those that don’t want to know more. I will leave you with something I read in a book I am reading for school (reference is Nickitas, below). It is a quote that completely strikes my funny bone, as probably the most ignorant comment about the Affordable Care Act…

Early in President Obama’s first term, when healthcare reform was being proposed, he reported receiving a letter from a woman who did not know the difference between a government and a private health insurance plan. She said, “I don’t want government-run health care. I don’t want socialized medicine. And don’t touch my Medicare” (Cesca, 2009)

Ok, she takes the cake for sure...

...and then for her official winner's certificate...


Nickitas, D. M. Policy and Politics for Nurses and Other Health Professionals, 2nd Ed. Chapter 2, page 15. Retrieved from an e-book online through Western Governors University.

Rosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports, 126 (1). Retrieved from

Wednesday, January 30, 2019

Nursing: Professional Presence and a Healing Environment

Achievement of success is reliant upon a winning merger of professional and personal life, and maintaining the healthy balance between them. One way you can attain this balance is to develop a professional presence plan that can be used to bridge the two worlds. Professional success in nursing depends upon the nurse’s self-knowledge and awareness, as well as the technical training and experiential practices. Various personality tools can be used to identify your your personality type, which can provide insight about how you think, plan, react, and self-manage.

This post will help you to explore self-awareness practices to increase the presence of mindfulness in your life and health care practice, by encouraging you to understand your strengths and weaknesses. It will also focus on professional presence, mindfulness practice, and healing environments. Utilizing the awareness gained from analyzing your thoughts, beliefs, and values, as well as your activities, relationships, and experiences, you can transform... and create a healing environment through the use of self-knowledge, active listening, authentic leadership, and mentoring.

Models of Health and Healing

According to Larry Dossey there are three eras of medicine between the 1860’s and current times (Koerner, 2011). Initially, illness was thought to exist as a physical response to brain functions. In the 1950’s we began to understand that illness presented with the culmination of physical, emotional, spiritual and mental aspects, internal to the patient.

It wasn’t until the 1990’s that the care models began to integrate external, social and spiritual components and how this metaphysical energy, both intangible and invisible, has a direct impact on patient health and healing. The core differences can be identified in the approach to care.

In Era I, providers sought only to reverse or correct the physical properties of the illness and used scientific facts and objective data to provide care. In Era II, providers began to understand that the subjective data the patient provided also had an impact on care—how and what the patient thought, felt, and understood resulted in variant outcomes. In the modern era of practice, there is a deeper understanding of the impact that the environment of care has in patient healing, and the patient’s own power in healing.

To be human is not just to have power over the mechanical or chemical components of the brain. It is the culmination of the physical, mental, spiritual, social, emotional, cultural, theoretical, and mechanical components that pertain to that patient.

Era III ushers a practice where there is greater consideration for the environment of care, and in order to promote a “healing environment” we must consider the human, and all that this means, to positively impact on patient’s health. The core difference in the eras then is based on consideration of internal versus external powers and the persuasion they have over the outcome of healing.

Models and Professional Presence

The environment of care has such an impact on patient outcome, as does the patient’s current human state. “[Mind-mediated phenomena] should inspire doctors to find more ways of treating the ills of the body by taking advantage of the powers of the mind and convince patients that those powers are always available to help restore lost health” (Weil, 2004, p. 234).

The Era I practices are comparable to the practices you have as a novice nurse, where you use a mechanical, textbook approach to care. You are not yet experienced enough to incorporate anything other than completing tasks, recording and reporting data, and advocating for patients in small ways. You may have since progressed through the levels of nursing experience to become a proficient clinician, and may have emerged to practice with intention, incorporating the needs of the patient and family in a meaningful way to promote an environment of healing.

Does your practice recognize the multitude of factors affecting patient outcome, including your beliefs, thoughts, and attitudes, and those of the patient? You must not allow your own beliefs or attitudes to obstruct the progress of patient healing, because your sole purpose as a nurse is to advocate for the patient in any way necessary.

Influence on Nursing Practice

Certainly your professional presence influences your nursing practice. If you are perceived to be competent, calm, self-assured and poised, it will promote an environment of trust and collaboration, which will in turn result in an increase of self-assurance, poise, competency, and composure. When this is perceived by the patient or fellow staff, it promotes a healing environment.

Many principles are used to promote healing presence in nursing practices. With self-knowledge, you begin to understand how you perceive your surroundings, and how you tend to react to situations. Knowing your personality type can be of great benefit as you learn to facilitate a healing environment. Knowing your personality traits as determined by the Meyers & Briggs typology test, enables you to be mindful in your practices. Use the principle of authentic leadership to influence the practices of others, and to unite in the common purpose of providing a healing presence to your patients.

Koerner defines healing presence as “the difference between safety and quality,” (p4 Koerner, 2011). I disagree with this definition and believe that healing presence is the bridge between safety and quality, not the difference. When I ask myself ‘what is the difference between the two,’ I think about how I define the two terms in this context. Safety, simply stated, is determined by the technical or mechanical aspects of providing patient care. Quality can then be determined by how that care was provided, focusing more on an emotional or mental application. Therefore the nurse’s healing presence does not differentiate between safety and quality, but rather bridges the obvious gap between the two.

Whole Person Goals

Mindfulness in essence, is self-reflection-in-action (Sherwood & Horton-Deutsch, 2012, p.80). In developing your own practice of mindfulness, you can create a plan to strengthen your health and balance in the physical, vital, mental, and spiritual bodies/aspects.

To be more mindful physically, it is important that you nourish your body and provide it with adequate exercise. You could prepare a menu on a weekly basis, to increase the opportunity to make smart and healthy food choices rather than fast food or processed foods.

To be more mindful in the vital/rhythmic aspect, you can institute a specific curfew for yourself by setting an alarm on your phone/watch. At that time, you would stop what you are doing and begin your bedtime routine. This cut-off time for you nightly, will enable you to achieve the recommended 6-8 hours of sleep each night.

You can also begin the practice of meditation using a phone app like Headspace. You can use the app daily as it suggests, and evaluate the effectiveness after seven days. Meditation will help to ease anxiety and focus your thoughts, and can help to prevent burnout as a nurse (Lichtenberg, et al., 2013).

To account for the mental and emotional balance, you can incorporate breathing exercises as an adjunct to the meditation. You can integrate the use of the 4-7-8 (Relaxing Breath) breathing exercise several times throughout the day and thoughtfully begin to practice it when you recognize that your stress level is high (Gonzalez, 2016). The act of intentional breathing is a “bridge between the conscious and unconscious minds” (p62, Weil, 2004). You can also read books for pleasure, to gain mental and emotional balance.

To achieve and maintain spiritual balance, you can look into attending church weekly, or complete daily scripture readings, or daily religious/gratitude journaling. This will help to restore a positive attitude and bring the realization that you are loved, cared for, and watched over.

Achievement of Goals

The wholeness of being human, involves attention to all of the aspects of mind, body, and spirit health. In order to achieve the goals you set for myself, you must continue to grow in the understanding that only balance among those aspects will bring ultimate health and allow you to help others in their pursuit of health and wellness. You can make a chart for yourself, to help sort the practices you plan to implement and to help meet the goal of mindfulness. Here is an example of a goal chart:

To adjust to the changing of your “whole person,” you will have to keep in mind why you chose to observe mindfulness. In order to become an agent of change you need to carry out changes in your own life.

Healing Environments: Best Practices

There are two facilities I have found in particular, that stand out in their patient care optimal healing environments. Their goal is to promote healing environments that reduce stress, anxiety, to speed healing, to shorten hospital stays, and to reduce the need for additional medications. Grinnell Regional Medical Center (GRMC) offers many different benefits in internal (spiritual care, meditation room), interpersonal (massage therapy, essential oils, café and dining options), behavioral (guided imagery, art therapy), and external environments (healing garden, bird aviary) (Grinnell Regional Medical Center, 2017).

The Johns Hopkins Hospital works to reduce the stress of hospitalization for the patient and family, incorporating artistic and aesthetic elements into the environment of care. They have rooms designed to be filled with sun, public spaces that are peaceful and elegant, ceiling tiles that absorb sound over patient care areas, gardens that are lush with landscaping designed for reflection and meditation, an art collection on display throughout their buildings, and animal sculptures in the children’s center. They have even included art images on the window shades in private patient rooms (Hopkins, n.d.).

Professional Presence Promotion

You can apply self-awareness and insights from review of the healing environments that were discussed, to promote professional presence in your current health care setting. As discussed in Management Learning by Becker, Jordan, and Messner in 2009, reflection plays a key role in organizational learning and has been based more on reflection-on-action than reflection-in-action. To engage staff in learning, it is important that they be enabled to learn and reflect as they go, so allowing time for review and reflection is a necessary element. Staff should be offered education on mindfulness practices, and encouraged to develop their own sense of mindfulness.

In the optimal healing environments discussed above, noise reduction was a key component to promotion of the healing process, both for the patient and for the family. Partnering with the patient, and allowing them time and space to “sort through the issues of the day, offering understanding and interpretation along the way” (p138, Koerner, 2011) is imperative to patient healing. You can begin to offer a quieter, safer, more supportive environment to your patients as a result of this research. There are areas where we can reduce stress for our patients through noise reduction on the unit, during changes of shift and nurse-to-nurse reporting practices. We can create an enhanced healing environment simply by ensuring that the patient room and bedside table are clean and free of debris and clutter.

We can begin to guide patients through their own mindfulness practices, and teach them non-medicinal techniques to manage their stress and pain – such as breathing exercises, meditation, darkening the room, decreasing environmental stimuli, or repositioning. There are many ways to initiate the use of mindfulness, self-awareness, and healing environments in your organization.

In Conclusion

Achievement of success is reliant upon a winning merger of professional and personal life, and maintaining the healthy balance between them. Adhering to a professional presence plan can bridge the two worlds. There is power in knowing that professional success in nursing can be secured through your own self-knowledge and awareness, as well as the technical training and experiential practices you have and those you will encounter.

In using personality tools to identify your personality type, you can explore self-awareness practices to increase the presence of mindfulness in your life and your health care practice, by understanding your strengths and weaknesses. You can more clearly focus on your professional presence, mindfulness practice, and the healing environment. You can transform and create a healing environment through the use of self-knowledge, active listening, authentic leadership, and mentoring.

George, B., Sims, P., McLean, A.N., and Mayer, D. (2007). Discovering your authentic leadership. Harvard Business Review. Reprint R0702H.

Gonzalez, B. (Ed.). (2016, May). Three Breathing Exercises And Techniques. Retrieved November 5, 2017, from Andrew Weil M.D. website:

Grinnell Regional Medical Center (Ed.). (2017, December 9). Optimal Healing. Retrieved from

Gustafson, C. (2016). James Gordon, MD: The Potential of Mind-Body Self Care to Free the World From the Effects of Trauma. Integrative Medicine: A Clinician’s Journal. 15(2), 54-60.

Hopkins Medicine. (n.d.). A healing environment. Retrieved November 12, 2017, from

Jordon (2009). Reflection & mindfulness in organizations. Management Learning.

Matsuo (2012). Leadership of learning and reflective practice: An exploratory study of nursing managers. Management Learning.

Koerner, J. (2011). Healing presence: The essence of nursing 2e. Springer Publishing Company. New York, NY. ISBN: 9780826107541

Lichtenberg Heard, P., Hartman, S., & Bushardt, S. C. (2013). Rekindling the flame: Using mindfulness to end nursing burnout. Nursing Management, 44 (11), 24-29.

Mendes, A. (2015). The role of nurses’ and patients’ beliefs in nursing care. British Journal of Nursing (Mark Allen Publishing), 24 (6), 345. Doi:10.12968/bjon.2015.24.6.345

Rassin, M. (2008). Nurses’ professional and personal values. Nursing Ethics, 15(5), 614-630 17p. doi: 10.1177/0969733008092870

Reid Ponte, P., & Koppel, P. (2015). Cultivating Mindfulness to Enhance Nursing Practice. American Journal of Nursing, 115(6), 48-55 8p. doi:10.1097/01.NAJ.0000466321.46439.17

Sherwood, G., & Horton-Deutsch, S. (2012). Reflective practice: Transforming education and improving outcomes. Indianapolis, IN, USA: Sigma Theta Tau International. ISBN: 9781935476795

The Myers & Briggs Foundation (Ed.). (2017). The 16 MBTI® Types. Retrieved November 22, 2017, from The Myers & Briggs Foundation website:

Weil, A. (2004). Health and healing: The philosophy of integrative medicine. Houghton Mifflin Co, New York, NY. ISBN: 9780395344309

Wednesday, September 9, 2015

A New View

A psychologist walked around a room while teaching stress management to an audience. As she raised a glass of water, everyone expected they'd be asked the "half empty or half full" question. Instead, with a smile on her face, she inquired: "How heavy is this glass of water?"

Answers called out ranged from 8 oz. to 20 oz.

She replied, "The absolute weight doesn't matter. It depends on how long I hold it. If I hold it for a minute, it's not a problem. If I hold it for an hour, I'll have an ache in my arm. If I hold it for a day, my arm will feel numb and paralyzed. In each case, the weight of the glass doesn't change, but the longer I hold it, the heavier it becomes."

She continued, "The stresses and worries in life are like that glass of water. Think about them for a while and nothing happens. Think about them a bit longer and they begin to hurt. And if you think about them all day long, you will feel paralyzed – incapable of doing anything."

Remember to put the glass down.

(I don't know who the author is so I am unable to give credit, but I did not write this myself! If you know who I need to credit, please comment or email me!)

Tuesday, June 16, 2015

Oral Nutrition Supplements: The RD Role in Wound Healing & Pressure Ulcer Prevention

I don’t really know what it was. Something in me compelled me to explore further. I knew that nutrition was important, why didn’t anyone else realize this? I had been a wound care nurse for three years, focusing in the outpatient wound clinic arena mixed with inpatient consults at 3 sister facilities.

Regardless of wound type, I always had the Braden Risk Assessment Scale on my mind as I generated the wound treatment plan, so the “prevention” thought process was there, somehow innate as a nurse. Years four through nine in wound care were spent running an inpatient wound care program for a 400-bed acute care hospital. I just knew that nutritional status had an enormous impact on patient wound healing, but I didn’t have evidence to back it up, because I hadn’t looked into it. I just knew it was more important than it got credit for… and then I began to learn about it first-hand.

I had several patient care scenarios where poor nutritional status was highlighted for me, but I couldn’t get anyone else to buy-in to the fact that it played such a huge part in the outcome. It took a few, eh-hem, serious and adverse learning opportunities, before anyone in leadership started to listen. I had the pleasure of meeting our facility’s RD early on, during the review of one such adverse event.

She was very knowledgeable, and had felt her own frustrations reach the tipping point, so it was truly a match made in heaven when we met and began to discuss an acute-care-world where nutrition was given the respect it deserves. She was so willing to learn about pressure ulcers and prevention, and she was equally open to sharing what she knew about nutrition with me. What we didn’t know, between the two of us, we sought to find out, and what each learned was shared immediately with the other. Finally! Someone who got what was in my brain! Why? Because NUTRITION was in my brain, and she was an RD!

We made a great team, each of us excited about what the other had to share. We had figured out how to improve our patient outcomes, and worked tirelessly to show that to anyone who had a role in patient care. We began to collaborate...not just talk here and there, but to actively communicate about the patients we were seeing. I began referring patients to the RD team, and she began informing the wound care team about patients with poor nutritional status. This open communication helped me to really understand what it meant to have an interdisciplinary team involved in the care of a patient.

We thought, “How can we make this better?” because by the time RD was brought in, there were already wounds present, or the patient was already malnourished. And by the time the wound care team was brought in on a patient, they already had a pressure ulcer or a wound. How could we empower the nurses to take action?? We both realized that for every Braden subscale category, there were actions the nurse could take to intervene, but for nutrition, the only action was passive: to initiate a referral to RD. We decided to change that.

What else could the nurse do for nutrition? We needed to empower the nurses with interventions that took action for the patient. So we did. We created an oral nutrition supplement protocol. The RD established criteria and I helped determine criteria for prevention of pressure ulcers or wound healing. Together we came up with 5 simple categories of triggers that the RN could easily identify, which would then be used in the decision tree for oral supplementation. The categories and triggers were:

If any of the 12 triggers were selected, the nurse was to use the decision tree to determine what oral nutritional supplement to begin for the patient. Factors considered in the decision tree included whether the patient was diabetic, if the patient had impaired renal function, and whether the patient needed tissue building. To initiate a protocol in the State of California, an MD order is required, so all it took was a TO from the MD to get nutrition initiated for the patient!

What we learned through this active, engaged collaboration between RD and Wound Care, was that we could make a big difference in the outcomes for our patients, if we opened up to each other and started utilizing the talents we each have, to focus our care for the patient.

Monday, June 8, 2015

Lippincott Stepping It Up with "How Caitlyn Jenner's Transition Affects Nursing Care"

Monday, June 8, 2015

I just received the greatest email in my inbox. Kudos to Lippincott for addressing current events and the effect on health care, specifically nursing practice. I hadn't thought of this being anything at all, but after receiving this email, I guess I have to expand my way of thinking. Again, KUDOS to them!! Here is what the email said:

Caitlyn Jenner, formerly known as Bruce Jenner, recently completed gender transition changing her physical appearance to align with her self-identification as a female. Last week Vanity Fair tweeted its latest cover featuring Jenner. This story has raised awareness of the struggles and misperceptions that are often faced by the lesbian, gay, bisexual, and transgender (LGBT) population. In our role, we need to be aware of special considerations in order to provide culturally-sensitive care to all patients.

On Lippincott NursingCenter, we have many resources that will provide you with the information you need to understand the unique health concerns of this population and overcome healthcare disparities.

Read the following CE articles free:

Caring for...Transgender Patients
Open the door for LGBTQ patients
Addressing Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices
Compassionately Caring for LGBT Persons in Your Faith Community
Culturally-Sensitive Care for the Transgender Patient

Additional resources can be found under the LGBT topic area on our site and for CE credit, we've bundled a selection of this content at a discounted rate in our LGBT CE Collection.

Also, be sure to check out our eBook, LGBTQ Cultures: What Health Care Professionals Need to Know About Sexual and Gender Diversity. This eBook serves as an overview and introduction to the health concerns and care for the LGBT community.

Thank you,
Lisa M. Bonsall, MSN, RN, CRNP
Clinical Editor
Lippincott NursingCenter

HOW COOL IS THAT EMAIL?? Thank you Lippincott!!! Helping us all to become better nurses and to continually show compassion for things we may otherwise not. I appreciate it!

Monday, April 13, 2015

Please vote to remove this add! Raises negative awareness toward ostomates!

Many nurses work very hard to help patients deal with the psychosocial challenges they face after having an ostomy. This ad does NOT support our efforts to enhance the patient's body image after ostomy!!!! The add suggests that an ostomy makes this woman "lesser" or unworthy. It associates feelings of guilt by suggesting it is her "punishment." This is not the image the public needs to have of any ostomate. We don't need this negative light shining on people with ostomies. The add portrays her as fearful to leave her home because it is "smelly" and she is afraid of leaks.

Please sign the petition to remove the add, by copying and pasting this link in your browser:

There are ways to target smoking cessation without causing undue judgment on someone who may already be suffering with concerns about body image and mortality. Don't give the public ammunition to further discrimination practices.

Sunday, February 15, 2015

My Lenten Challenge -- 6 Weeks to Enrichment

You have 6+ weeks of Lent, to work at accomplishing at least one, and maybe more, of the below "desired things to accomplish." Good Luck!

1. Things I would do, if I had more time...

2. People I would visit, in person, or by letter, if there were more time...

3. Things I would like to get done, if only I had more time...

4. I would make these things better about myself, if only I had more time...

5. I would volunteer to do this thing (or these things), if only I had more time...

6. If I had more time to do it, I would...

I hope you take this time during Lent, to work on something that will enrich your life or the life of others. It always seems to take something big to make a change, or a trigger to make things happen. Let this Lent be your trigger!