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November 2014 Special Edition
www.AmericanNurseToday.com
BEST OF THE BEST
Publication
Inside ANA Strictly Clinical Practice Matters Career Sphere Mind/Body/Spirit Leading the Way
Editorial Staff
Editor-in-Chief
Lillee Smith Gelinas, MSN, RN, FAAN
System Vice President and Chief Nursing Officer
Clinical Excellence Services
CHRISTUS Health
Irving, Tex.
Editorial Advisory Board

Rhonda Anderson, DNSc(h), RN, FAAN, FACHE
Chief Executive Officer
Cardon Childrens Medical Center
Mesa, Ariz.
Carolyn Buppert, CRNP, JD
Health Care Attorney
Law Office of Carolyn Buppert, P.C.
Boulder, Colo..
Jim Cato, EdD, RN, CRNA
System Chief Nurse Executive
CHRISTUS Spohn Health System
Corpus Christi, Tex.
Nancy Dunton, PhD, FAAN
Research Professor
School of Nursing
University of Kansas Medical Center
Kansas City
Michael L. Evans, PhD, RN, NEA-BC, FAAN
Dean and Professor
Texas Tech University Health Sciences Center
School of Nursing
Lubbock, Tex.
Margaret A. Fitzgerald, DNP, APRN, BC, NP-C,
FAANP, CSP
President, Fitzgerald Health Education Associates,
Inc.
North Andover, Mass.
FNP, Adjunct Faculty, Family Practice Residency
Greater Lawrence Family Health Center, Inc.
Greater Lawrence, Mass.
Melissa Fitzpatrick, MSN, RN, FAAN
Vice President and Chief Clinical Officer
Hill-Rom
Batesville, Ind.
Karen F. Flaster, RN
Chief Operating Officer
HRN Services Inc.
Beverly Hills, Calif.
Gwendylon E. Johnson, MA, RNC
Nurse Coordinator, Womens Health
Howard University Hospital
Washington, DC
Norma M. Lang, PhD, RN, FRCN, FAAN
Professor and Dean Emeritus
School of Nursing
University of Pennsylvania
Philadelphia
Wisconsin Regent Distinguished Professor and Aurora
Professor of Health Care Quality and Informatics
College of Nursing
University of Wisconsin
Milwaukee
Gail Pisarcik Lenehan, EdD, RN, FAEN, FAAN

Nurse Clinical Specialist
Emergency Department
Massachusetts General Hospital
Boston
Julianne Morath, MS, RN
Hospital Quality Institute
Sacramento, Calif.
Rebecca M. Patton, MSN, RN, CNOR, FAAN
Former President, American Nurses Association
Atkinson Visiting Instructor
Frances Payne Bolton School of Nursing at Case
Western Reserve University
Cleveland, Ohio
Ginette A. Pepper, PhD, RN, FAAN
Director, Hartford Center of Geriatric Nursing
Excellence
Professor & Helen Bamberger Colby Endowed Chair
in Gerontologic Nursing
Associate Dean for Research and PhD Programs
University of Utah College of Nursing
Salt Lake City
Therese Richmond, PhD, FAAN, CRNP
Andrea B. Laporte Endowed Term Associate
Professor of Nursing
University of Pennsylvania School of Nursing
Philadelphia
Cass Piper Sandoval, MS, RN, CNS, CCRN
Clinical Nurse Specialist
Cardiovascular Critical Care, University of California,
San Francisco Medical Center
San Francisco
Franklin A. Shaffer, EdD, RN, FAAN
CGFNS International
Philadelphia
Roy L. Simpson, RN, C, CMAC, FNAP, FAAN
Vice President, Nursing
Cerner Corp.
Kansas City, Mo.
Kathleen M. White, PhD, RN, NEA-BC, FAAN
Associate Professor and Director for the Masters
Program
School of Nursing
Johns Hopkins University
Baltimore, Md.
May L. Wykle, PhD, RN, FGSA, FAAN
Marvin E. and Ruth Durr Denekas Professor
Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, Ohio
Susan Wysocki, WHNP-BC, FAANP
President
iWomansHealth
Washington, DC
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American Nurse Today Best of the Best
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these with recommendations of other authorities.
F EATURES
Dispelling pain myths
Beware of oversimplifying mealtime insulin dosing for

hospital patients
By Lora McGuire and Pam Bolyanatz

Erroneous assumptions about pain run counter to evidence-based best practices for managing pain.
By Julie S. Lampe
Insulin administration involves a complex decision-making process. Find out how to reduce the
risk of adverse outcomes in hospital patients receiving this drug.
D EPARTMENTS
Inside ANA
Alcohol screening and brief intervention:
A clinical solution to a vital public health issue
By Nancy E. Cheal, Lela McKnight-Eily, and Mary Kate Weber
Alcohol screening and brief intervention is a fast, inexpensive technique that can lower the amount
a person drinks by 25% per occasion.
Strictly Clinical
11
R APID R ESPONSE
A swift, decisive response to GI bleeding

By Ira Gene Reynolds
A patients sudden nausea, coffee-ground emesis, low blood pressure, and fast heart rate trigger
interventions to staunch acute upper GI bleeding.
Practice Matters
12
T HE H UMAN S IDE
OF
PATIENT S AFETY
Managing our fears to improve patient outcomes

By Susan Tocco and James DeFontes
If youre afraid to speak up when you see a colleague making a serious mistake, you probably
work in an environment where you feel psychologically unsafe.
Career Sphere
16
Stop: A strategy for dealing with difficult conversations

By Kathleen Pagana
When the going gets tough, the tough can use this simple and effective four-step process to
confront someone about a prickly topic.
Mind/Body/Spirit
18
What to do when someone pushes your buttons

By Laura L. Barry and Maureen Sirois
Having your buttons pushed is uncomfortable but unavoidable. Learn how to embrace it by digging
deeper to unearth unresolved wounds.
Leading the Way

20
What you can learn from failure

By Rose O. Sherman
To bounce back from a failure, analyze why it happened and learn how to use it to help yourself
and others.
November 2014
Inside ANA
Issues up close
Alcohol screening and brief intervention: A clinical solution

to a vital public health issue
What is risky alcohol use and why is it important to health?
By Nancy E. Cheal, PhD, RN; Lela McKnight-Eily, PhD; and Mary Kate Weber, MPH
RISKY
OR EXCESSIVE alcohol use is common, expensive, and underrecognized as a significant public

health problem. Its also not addressed adequately in
healthcare settings. At least 38 million U.S. adults
drink too much. Drinking too much includes binge
drinking, high weekly alcohol consumption, and any
drinking by those under age 21 or pregnant women.
Risky alcohol use cost the United States $224 billion
in 2006. Its the third-leading preventable cause of
death, contributing to a wide range of negative health
and social consequences, including motor vehicle
crashes, intimate partner violence, and fetal alcohol
spectrum disorders. Over time, it can result in serious
medical conditions, such as hypertension, gastritis,
liver disease, and various cancers. Despite alarming
statistics and serious health and societal harms,
healthcare providers dont routinely talk with their
patients about alcohol use.
Understanding how much drinking is too much

isnt widely understood by the public or healthcare
providers. Most people think that drinking too much
means that a person is an alcoholic or alcohol dependent. However, data show that only about 4% of
adults are alcohol dependent and another 25% arent
dependent but drink in ways that put themselves and
others at risk of harm.
Definitions of excessive drinking in the United
States are shown in the graphic below. Also important,
consuming more than one drink a day for women or
more than two drinks a day for men has been shown
to have negative health effects. In addition to pregnant
women and those under the legal drinking age, any
consumption is too much for individuals who are dependent on alcohol or unable to control the amount of
alcohol they drink. Furthermore, alcohol is contraindicated with many medications. Therefore, individuals
Drinking too much includes
Source: CDC. www.cdc.gov/vitalsigns/alcohol-screening-counseling/infographic.html
taking certain prescription drugs, those who have

medical conditions that can be made worse by alcohol, and persons driving, planning to drive, or doing
other activities that require skill, alertness, and coordination should limit or abstain from alcohol use.
What can be done?

Alcohol screening and brief intervention (SBI) is an
effective, quick, and inexpensive clinical preventive
service that can reduce the amount a person drinks
per occasion by 25%. The U.S. Preventive Services
Task Force (USPSTF), multiple federal agencies, and
other health organizations have recommended that alcohol SBI be implemented for all adults in primary
healthcare settings (including pregnant women) due
to strong evidence of its effectiveness. Furthermore,
in 2011 the American Nurses Association released a
revised position statement supporting nonpunitive alcohol and drug treatment for pregnant and breastfeeding women and their exposed children.
on the results of this discussion, help the patient

come up with a plan.
4. Close on good terms, regardless of the patients response.
How can nurses intervene?

Nurses are trusted healthcare providers and are
uniquely positioned to provide and change practice
in many settings. In fact, a number of studies report
that nurses providing alcohol SBI have had excellent
results.
To actively promote implementation of alcohol
SBI, nurses can:
become familiar with levels of risky drinking
understand and share with others how well alcohol SBI works
learn how to conduct alcohol SBI with patients effectively
champion and support the integration of alcohol
SBI into routine primary care.
What is alcohol screening and brief intervention?
Available resources
Alcohol SBI is a preventive service similar to hypertension or tobacco screening. It identifies and provides help to patients who may be drinking too
much. It includes:
a validated set of screening questions to identify
patients drinking patterns. These can be administered orally or on a form. The USPSTF recommends the use of the Alcohol Use Disorders
Identification Test (AUDIT, U.S. version), the brief
three-question version of this measure called the
AUDIT-C, or a single-question screener for heavy
drinking days (such as, How many times in the
past year have you had five or more drinks in a
day [for men] or four drinks [for women]?)
a short conversation with patients who drink too
much. Generally, a conversation of 6 to 15 minutes
is effective for a brief intervention. For the small
percentage of patients who are alcohol dependent,
a referral to treatment is provided as needed.
Alcohol SBI can be integrated into a routine medical visit. The four key steps to keep in mind when
performing this service are the following:
1. Ask the patient about his or her drinking using a
validated screening instrument. If the patient reports drinking more than the levels indicated in the
graphic or the cut-offs for the screening instrument,
conduct a brief intervention as described below.
2. Talk with the patient, using plain language, about
what he or she thinks is good and not so good
about their drinking.
3. Provide options by asking the patient if he or she
wants to stop drinking, cut down, seek help, or
continue with the current drinking pattern. Based
A number of excellent resources are readily available

online on how to conduct alcohol SBI. Two helpful
resources developed by the National Institute on
Alcohol Abuse and Alcoholism include Helping
Patients Who Drink Too Much: A Clinicians Guide
and a booklet and website called Rethinking
Drinking (http://rethinkingdrinking.niaaa.nih.gov).
Although individual nurses or other healthcare professionals should conduct alcohol SBI, implementation planning for their specific healthcare settings is
needed to make it routine. The Centers for Disease
Control and Prevention have developed step-by-step
implementation guides for alcohol SBI in trauma centers and primary care settings. These guides help an
individual or small planning team adapt alcohol SBI
into their standard practice.
Risky alcohol use is a significant and costly public
health problem that has not been addressed adequately despite the availability of effective interventions. Alcohol SBI works to reduce excessive alcohol
use in persons who drink. Nurses can champion the
routine implementation of alcohol SBI and deliver it
effectively in a variety of settings, helping adult patients reduce excessive alcohol use and influencing
clinical practice to effect population-level change. O
Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.
Nancy E. Cheal is a research health scientist, Lela McKnight-Eily is an

epidemiologist, and Mary Kate Weber is a public health analyst at the
Centers for Disease Control and Prevention in the National Center on
Birth Defects and Developmental Disabilities, Fetal Alcohol Syndrome
Prevention Team.
November 2014
Read up on the latest evidence-based best practices

in pain management.
By Lora McGuire, MS, RN, and Pam Bolyanatz, MS, APN, FNP-BC
UNLESS MANAGED aggressively,

acute pain (defined as pain lasting
a few seconds to about 3 months)
may progress to chronic or persistent pain. This progression stems
from central sensitization (sometimes called wind-up syndrome),
in which increased sensitivity to
unrelieved pain makes neurons
more excitable, leading to central
nervous system changes.
Continuous stimulation of peripheral nerves activates group C nerve
fibers, causing a progressively increasing electrical response and
hyperexcitability. This can result in
chronic pain syndrome.
As healthcare professionals, we
need to manage our patients acute
pain effectively to help prevent hospital readmissions necessitated by
pain and to prevent chronic pain
syndrome. To do this, we need to
separate the facts about pain from
the myths. This article dispels pain
myths using actual cases (names
have been changed) and discusses
best practices for patients with pain.
Pain myth #1: Standard

analgesic dosages are effective
for all postoperative patients
A 48-year-old female (well call her
Susan) is admitted for intractable
back pain. Her pain rating is 9 on
a 0-to-10 scale. Comorbidities include degenerative hip disease of
the right side and multiple sclerosis.
She has had more than 10 previous
surgeries and many episodes of unrelieved pain. For 10 years, she took
up to six hydrocodone/acetaminophen tablets daily. She also has
an undiagnosed anxiety disorder.
When a magnetic resonance im4
aging (MRI) scan reveals a new disc

herniation at the site of a previous
laminectomy, the physician prescribes conservative treatment, including a lumbar epidural steroid
injection, oral steroids, I.V. opioids,
and physical therapy. Nonetheless,
Susans pain persists and grows
even worse.
The physician then recommends
a microdiscectomy. After the procedure, Susans postoperative course
is managed via patient-controlled
analgesia (PCA) with hydromorphone I.V. 0.3 mg every 8 minutes,
with a 10-minute lockout for the
first 24 hours, until she can tolerate
oral fluids. Her pain rating on PCA
therapy is 3 on a 0-to-10 scale
(3/10), and shes reluctant to have
the PCA discontinued. However, she
begins to receive extended-release
oral morphine 30 mg every 12
hours. To reduce the amount of opioids, the healthcare team initiates a
multimodal pain-management regimen, which includes the muscle relaxant baclofen 10 mg P.O. every
8 hours, two lidocaine (Lidoderm)
patches applied to intact skin (12
hours, 12 hours off), and the anxiolytic hydroxyzine 50 mg P.O. every
6 hours as needed.
As this case study shows, standard analgesic dosages may not be
effective in postoperative patients.
Susan had persistent (chronic) pain
for many years caused by multiple
sclerosis and degenerative hip disease. Although her persistent pain
previously had been fairly well
controlled, her healthcare team is
now challenged by her acute postoperative pain. Her history of
chronic pain may necessitate high-
er-than-standard analgesic dosages

to control postoperative pain.
Although medication is the mainstay of acute pain management,
nonpharmacologic options should
be tried as well to ease discomfort.
Before a nonpharmacologic method
begins, explain to the patient how
the technique works based on the
gate control theory of pain. This theory proposes that all pain sensations
pass through a gating or control
mechanism in the dorsal horn of the
spinal cord. When more small nerve
fibers than large nerve fibers are
stimulated, the gate opens and pain
impulses travel to the brain, where
pain is perceived. Complementary
and alternative techniques (such as
relaxation and distraction) cause
stimulation of more large nerve
fibers, which is thought to cause the
gate to close. Taking the time to explain the rationale in simple language shows patients you care and
want to ease their discomfort.
On day 3, Susan rates her pain
as 6/10 and experiences muscle
spasms in her paraspinal muscles.
Her muscle relaxant is changed to
tizanidine 4 mg P.O. every 8 hours
as needed. Multimodal therapy includes ice applied to the surgical
site for 20 minutes every 4 hours
and physical therapy assistive devices (a grabber and a walker).
Susans pain is more challenging
to manage than many other patients,
partly because of her history of multiple surgeries, opioid tolerance, and
undiagnosed anxiety disorder.
Multimodal management allows
a decrease in Susans opioid dosage.
She tolerates tizanidine better than
baclofen, so shes now more able to
participate in physical therapy. She

states, I was always so anxious
about my pain. Now my anxiety is
lessened, and I dont need anxiety
medication because my pain is controlled. At discharge, she reports a
pain rating of 3/10 and thanks the
nursing staff for the high-quality
care they provided.
Pain myth #2: Older adults
shouldnt receive chronic opioid

therapy
An 88-year-old female whos not a
native English speaker is brought to
the emergency department by her
husband. The electronic medical
record indicates that Pradnaya has
had multiple readmissions due to
compression fractures and pain.
During the intake process, she is
unable to rate her pain when the
nurse asks her to, but the nurse assumes shes experiencing pain
based on her compression fractures
and her obvious moaning. When
moved to the table machine for an
MRI, Pradnaya just cries and
moans. Her husband reports she
stopped taking her prescribed hydrocodone/acetaminophen because
it caused constipation and she hated using it. He states, "We dont
want her to take it any more."
Medication refusal is common in
older adults. If patients keep refusing pain medication, theyll begin
to decline due to physical dysfunction. If your patient refuses pain
medication, realize there may be
more to the story. Perhaps he or
she cant afford the medication,
doesnt understand how to take it,
or (like Pradnaya) cant tolerate the
side effects.
So what are best practices for a
patient like Pradnaya? To address
the language barrier, use an interpreter to interview her and find out
why she stopped taking her pain
medication. In Pradnayas case, the
interpreter confirmed that it was
constipation.
Through the interpreter,
Pradnaya and her husband receive
Common nonopioid drugs used for acute pain

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to
relieve acute pain. Acetaminophen injection (Ofirmev) typically is given as 1,000
mg by I.V. piggyback every 6 hours for 24 hours. It may be administered for another
24 hours in patients on nothing-by-mouth status.
Ketorolac, an NSAID, usually is given as 30 mg by slow I.V. push every 6 hours.
For patients older than age 65 and those with diminished renal clearance or function (creatinine clearance below 30 mL/minute), give 15 mg instead. Dont administer this drug longer than 5 days.
Caldolor (ibuprofen in water for injection) is a newer parenteral NSAID commonly given as 400 to 800 mg by I.V. piggyback for 30 minutes every 6 hours.
education on the purpose of pain

medication as well as treatment
and prevention of side effects. In the
hierarchy of pain assessment, selfreport is the gold standard. But with
a patient like Pradnaya whos unable to self-report, caregivers should
keep in mind that she has a pathologic condition that can be expected
to cause pain. The physician decides to prescribe a 24-hour analgesic trial of around-the-clock oxycodone 5 mg P.O. every 6 hours to
determine if it reduces her pain
and improves physical function.
Opioids arent contraindicated
for older adults, but they should be
started at a low dosage and titrated
upward slowly. Many older adults
have multiple comorbidities that can
result in more serious adverse effects. Prevention and treatment of
opioid-induced constipation is managed mainly by the bedside nurse
and should begin when the opioid
is started. Nurses must be proactive
about bowel function in all patients
taking opioids. Patients dont build
a tolerance to this side effect, which
significantly affects overall health.
The nurse is able to find a pain
rating scale (0-10) in Pradnayas
native language. After 24 hours of
oxycodone therapy, Pradnaya rates
her pain as 2/10. To help prevent
constipation, the nurse starts her on
senna (a nonprescription laxative)
and docusate sodium (a nonprescription stool softener) twice daily.
After several days, her constipation
resolves. On discharge, she rates her
pain as 3/10 with activity. She verNovember 2014
balizes to her husband that she will

adhere to the drug regimen.
The dangers of labeling patients

as drug seeking
Some healthcare professionals may
label certain patients who come in
frequently as drug seeking. But
we need to ask ourselves how such
labeling advances the patients care.
Does it truly promote the nurses
role as patient advocate? When a
coworker refers to a patient this
way, do you stop and discuss the
problems that can result from patient labelingor do you bypass
the discussion because youre busy
and wish to avoid whats likely to
be an uncomfortable conversation?
Addressing patient labeling and
misconceptions is crucial to providing the best possible care.
Because were human, we may
find it hard to care for challenging
patients. If you find yourself not believing or trusting a patient, speak
with your manager. Consider asking
that the patients care be transferred
to another nurse for that shift; although not an ideal solution, this
gives the patient a better chance of
getting the best care possible. Then
further reflect on why you dont believe or trust the patient, and think
about how you can resolve your
feelings in the future. Your manager
should be happy to support you.
Best practices in pain

management
When appropriate, healthcare
givers should use multimodal ap-
Common opioids used for acute pain

Morphine, the gold standard, is hydrophilic. (Hydrophilic agents are absorbed more
slowly than lipophilic agents and take longer to cross the blood-brain barrier.) A
10-mg intramuscular dose is equianalgesic to a 30-mg oral dose. It can be given by
any route. Dont break or crush sustained-release formulations; instruct the patient
not to chew them.
Hydromorphone, also hydrophilic, is 80 times more potent than morphine.
A 1.5-mg intramuscular dose is equianalgesic to an oral dose of 7.5 mg. A longacting, once-daily hydromorphone formulation is now available.
Fentanyl is 100 times more potent than morphine. Lipophilic, its prescribed in
micrograms, not milligrams, and can be given by various routes. The transdermal
patch is used for chronic pain only.
proaches to pain management.

Multimodal analgesia combines different classes of medications that
fight pain through different mechanisms, which can make pain management more effective. Some medications add analgesic effects;
others work synergistically. The patient can receive lower dosages of
each medication and experience
fewer adverse effects.
Pharmacologic management of
acute pain may include:
opioids
nonopioid drugs, such as I.V. or
oral acetaminophen, I.V. ketorolac, or oral nonsteroidal anti-inflammatory drugs (NSAIDs)
adjuvants, such as muscle relaxants, anticonvulsants, and antianxiety agents. (See Common nonopioid drugs used for acute pain.)
Commonly used opioids include
morphine, hydromorphone, and
fentanyl. Oral or I.V. administration
(or both) are recommended.
Codeine isnt recommended because of genetic variances in how
this drug is metabolized and absorbed. Several pharmaceutical
companies are working to develop
tests or markers that allow healthcare professionals to identify the
most effective analgesics for individual patients. (See Common opioids used for acute pain.)
Here are some other best practices for pain management:
Advocate for pain management
for all patients.
Assess pain regularly using an
6
appropriate pain scale.

Make pain visible in the hospital setting. For instance, advocate
for a hospital-wide campaign so
patients, families, and visitors can
see that pain control is a priority.
Avoid labeling and judging patients.
Ask the patient, Is there anything we can do to make you
more comfortable?"
Treat pain early instead of waiting for it to become more severe.
Consider the patients age, culture, religion, and socioeconomic
status when developing a painmanagement plan.
Assume pain is present. To evaluate analgesic effectiveness, use
a 24- to 48-hour around-theclock analgesic trial for patients
with obvious pain.
Beware of the risk of acetaminophen toxicity. Keep the total daily dosage below 4,000 mgeven
lower for older adults.
Give the lowest dosages of
NSAIDs possible for the shortest
duration to avoid complications,
such as peptic ulcers, GI bleeding, and cardiovascular disease.
Assist prescribers in choosing an
appropriate analgesic for your
patients pain levelfor example,
nonopioids or tramadol for mild
pain; oxycodone or hydrocodone
for moderate pain; or morphine,
oxycodone, hydromorphone, or
fentanyl for severe pain.
If possible, give only one opioidpreferably a long-acting
opioid and a short-acting formulation of the same opioid (if one

is available). This will simplify
the regimen.
Administer adjuvant analgesics,
such as anticonvulsants, muscle
relaxants, and antispasmodics, as
appropriate.
Use nonpharmacologic interventions as needed to enhance pain
relief.
Regularly evaluate the effectiveness
of the pain-management plan.
Nurses role
According to Ann Schreier, past
president of the American Society
for Pain Management Nursing,
Every nurse is a pain-management
nurse. In acute-care settings, nurses should empower and educate
patients and families about pain
and its management. Make pain
management be a high priority.
Urge your organizations leaders
to make pain more visiblefor
instance, with appropriate signs,
whiteboards, TV monitors, and
handouts of the Pain Care Bill of
Rights (from the American Pain
Foundation). Many hospitals have
created pain-awareness campaigns
that feature pain teams and painresource nurse programs.
Our messaging should incorporate appropriate and positive communications, such as What can we
do to make you more comfortable?
As nurses, we know never to promise patients that a medication or
other treatment will take away all
of their pain. But if we can treat
pain before it gets severe, help
make it more tolerable, and increase patient functioning, were
giving the best care we can.
O
Visit www.AmericanNurseToday.com/Archives/
aspx for another case study illustrating a pain
myth, nonpharmacologic pain-management
options, and a list of selected references.
Lora McGuire is a clinical educator at Presence St.

Joseph Medical Center in Joliet, Illinois. Pam Bolyanatz
is an inpatient pain-management nurse practitioner
at Cadence Health Delnor Hospital in Geneva, Illinois.
Beware of oversimplifying
mealtime insulin dosing
for hospital
patients
Learn how to
make clinical
decisions more
confidently for
patients on
insulin.
By Julie S. Lampe, MSN, CNS, CNS-BC,
ADM-BC
IT S LUNCHTIME. Three of your

patients are scheduled to receive
rapid-acting insulin in addition to
sliding-scale insulin.
Mr. Jones, age 87, has type 2 diabetes. His blood glucose level
is 223 mg/dL. Hes on a clear
diet.
Mrs. Smith, age 63, has type 1
diabetes, a serum creatinine level of 1.6 mg/dL, an inconsistent
appetite, and widely varying
blood glucose levels. Her current blood glucose level is 105
mg/dL.
Mr. Brown, age 58, has pneumonia, type 2 diabetes, and obesity;
hes receiving corticosteroids. He
eats everything on his tray and
asks for snacks. His lunchtime
blood glucose level is 152
mg/dL. By the time youre able
to administer his insulin, he has
eaten half his lunch tray.
Which patient should receive insulin as scheduled? Should any of
them not receive it? Should any receive scheduled insulin plus the
sliding-scale dose? What should
you do if one of them has a normal blood glucose level? Are any at
risk for hypoglycemia? What could
happen if they eat before you can
administer insulin?
These are questions you might
ask yourself every day but rarely
have the time or resources to get
the answer. Yet to make safe clinical decisions, you need the required knowledge base, because
insulin is strongly linked to med-
November 2014
Comparing short- and rapid-acting insulin

This table summarizes the pharmacokinetics of rapid-acting insulin and regular insulin.
Insulin type
Names
Onset of action
Peak effect
Duration of action
Rapid-acting analog insulin Insulin aspart

Insulin glulisine
Insulin lispro
5 to 15 minutes
1 to 2 hours
3 to 4 hours
Short-acting insulin
30 to 45 minutes
2 to 4 hours
5 to 7 hours
Regular insulin
Human insulin
ication errors and adverse drug

events (ADEs). The American
Hospital Association deems coordination of meals and insulin a top
priority for reducing in-hospital
ADEs.
The variety of insulin types and
their wide-ranging pharmacokinetic
properties further complicate insulin use in the hospital. Whats
more, much variation exists in the
insulin regimens used to meet
blood glucose goals recommended
by regulatory bodies and professional organizations, such as The
Joint Commission and the
American Diabetes Association.
out significantly increasing hypoglycemia occurrences.

Basal-prandial insulin therapy
has three components:
long-acting insulin given once or
twice daily
rapid-acting insulin given in prescribed doses with meals
correction insulin given with
meals and at bedtime. (See
Comparing short- and rapid-acting insulin.)
Basal-prandial regimens may involve more insulin than youre
used to giving with traditional sliding-scale and stand-alone regimens. This may make you hesitate,
particularly at mealtimes, when
you may be giving higher doses of
rapid-acting insulin. A clear understanding of the pharmacologic
principles of basal-prandial insulin
and how its prescribed will boost
your confidence.
Unlike traditional sliding-scale
regimens, which are reactive, basalprandial regimens address the patients insulin requirements proac-
Basal-prandial insulin therapy

One insulin regimen involves
basal-prandial insulin therapy. This
therapy became popular after publication of the RABBIT 2 trial in
2007, which compared stand-alone,
sliding-scale insulin therapy with a
basal-prandial insulin regimen. It
found that the latter decreased
mortality and complications with-
tively. With these regimens, dosages

are calculated based on the patients weight and estimated insulin sensitivity. Defined as the
patients expected response to
1 unit of insulin, insulin sensitivity
can vary widely among patients
and depends on several factors.
For instance, patients with renal
failure, advanced age, and type 1
diabetes tend to be more insulinsensitive. In contrast, those with
obesity, type 2 diabetes, or infections and those receiving steroids
tend to be more insulin-resistant.
Once the patients insulin sensitivity is determined, a sensitivity
factor is selected and multiplied by
the patients weight in kg; the result is the total daily dosage of insulin. Half of the total dosage is
given as basal insulin and the remainder is divided by three and
given with meals. (See Calculating
basal-prandial insulin.)
Each part of the basal-bolus regimen serves a specific purpose:
Long-acting insulin meets basal
Calculating basal-prandial insulin

This chart shows how to calculate total daily insulin doses, basal insulin doses, and prandial insulin doses for the three fictitious patients discussed in the article. Calculations for each patient are based on weight, insulin sensitivity factor, and pertinent comorbid
medical conditions.
Patient
Weight
Insulin
sensitivity
factor
Mr. Jones
191.8 lb (87 kg)
0.4 units/kg/day
35 units/day
18 units/day
6 units t.i.d. with meals
Mrs. Smith
119 lb (54 kg)
0.3 units/kg/day
16 units/day
8 units/day
Mr. Brown
231 lb (105 kg)
0.5 units/kg/day
53 units/day
26 units/day
Total
daily
dose
Basal
insulin
doses
Prandial
insulin
doses
Generic correctional insulin scale

This table shows a typical correctional insulin scale for patients with moderate insulin resistance.
Blood glucose level (mg/dL)
Correctional insulin
< 70
Intervene according to hypoglycemia

protocol and notify physician.
71 to 199
0 units
200 to 249
4 units
250 to 299
6 units
300 to 349
8 units
> 350
10 units; call physician.
insulin requirements and is designed to match the livers continuous glucose output.
The prandial rapid-acting insulin
component covers the carbohydrate bolus that the patient eats
at each meal.
The correction coverage addresses blood glucose levels outside the target range and is
dosed on a sliding scale based
on blood glucose levels. (See
Generic correctional insulin
scale.)
Mealtime insulin and food

intake
Mealtime boluses of rapid-acting
insulin should be given with 30 to
60 g of carbohydrates. But few patients count carbohydrates in the
hospital. So how do you know
how much carbohydrate a patient
consumes? Typically, hospital patients on a diabetic diet receive
1,800 calories per day. On an
1,800-calorie diet tray, the carbohydrate portion of one meal is about
60 to 75 g. That means the patient
must eat about 50% of the tray
consistently to receive the prescribed prandial boluses. A patient
like Mrs. Smith, with an inconsistent appetite, normal blood glucose
level, and poor renal function,
needs to be evaluated at each meal
to determine how much insulin to
give. If she eats a full meal, you
may administer a full prandial
dose; if she eats less than 50% of
attending physician to clarify the

correctional insulin dose.
Mealtime blood glucose levels

and insulin administration
her meal, call the physician for

clarification. Ideally, patients like
her should have standing orders on
how to proceed when they eat less
than 50% of a meal (if such orders
arent part of the facilitys basalbolus order set). You might suggest
that the physician address the variable prandial doses by writing a
standing order to cover future
meals so you dont have to call
him or her.
If you administer insulin to patients receiving basal-prandial insulin, consider the type of diet
theyre on. Here are some examples:
Patients receiving nothing by
mouth (NPO) shouldnt receive
prandial boluses.
Those on clear liquid diets dont
consume enough carbohydrate
to warrant prandial insulin administration. Typically, theyre
on these diets to rest the gut
therapeuticallyfor instance, because of a poor appetite or nutritional absorption problems.
If your patient is NPO or on a
clear liquid diet and has an order
for prandial insulin boluses, clarify
the order with the attending physician. Take, for instance, Mr. Jones
the 87-year-old on a clear liquid diet whose blood glucose level is 223
mg/dL. He needs insulin to reduce
his blood glucose to a normal level
to avoid further hyperglycemia,
but not so much insulin that hypoglycemia occurs. So you need to
withhold prandial insulin. Call the
November 2014
Although youll need to assess nutritional intake at each meal for

mealtime boluses, you should give
correctional insulin as indicated regardless of diet type, appetite, and
overall intake. Correctional insulin
aims to correct the blood glucose
level based on the premeal glucose
level. Ideally, measure blood glucose as close to mealtime and insulin administration as possible.
This helps ensure that the insulin
dose you give is appropriate for
the patients current blood glucose
level to prevent over- or underdosing, which could lead to hyper- or
hypoglycemia.
You may be concerned (legitimately so) about giving insulin
when a patient is NPO. Many hospitals have adopted NPO correction
scales. Typically, these scales provide reduced insulin coverage and
begin covering blood glucose at a
much higher level. This level depends on target blood glucose
goals set by the hospital. If your
hospital doesnt have an NPO sliding scale, review the patients
blood glucose levels with the attending physician to determine if
he or she should receive insulin
while NPO.
Although you may feel comfortable giving insulin when the patients blood glucose level is elevated, you may have concerns about
giving scheduled insulin doses
when the glucose level is normal.
Rememberthe purpose of prandial insulin is to cover the carbohydrate consumed in a meal, so you
should give prandial insulin boluses even if the blood glucose level
is 70 to 140 mg/dL, as with Mrs.
Smith. Because she has type 1 diabetes and doesnt produce insulin,
she must receive exogenous insulin
even when her blood glucose level
is normal to avoid diabetic ketoaci-
dosis. But if a patient has a blood

glucose level below 70 mg/dL,
treat the blood glucose according
to your hospitals hypoglycemia
protocol and notify the attending
physician. As part of the hypoglycemia notification process, review all premeal blood glucose
levels and scheduled prandial insulin doses.
administration with
Coordinating meals and insulin
the first bite of food can
Coordinating insulin administration

with meals can be a daunting task.
Mealtimes are often the busiest
times of a nurses day. You may
have other medications to give and
other tasks to do. But timing insulin administration with the first
bite of food can reduce the risk of
periprandial hypoglycemia and
subsequent blood glucose variability. To avoid variability, administer
mealtime boluses within 15 minutes before or after the first bite.
Prandial insulin doses are given
as rapid-acting insulin. To understand the rationale for the administration times, you must be familiar
with the pharmacokinetics of rapidacting insulin. Its an analog insulin, meaning its chemically engineered to be absorbed more
rapidly in the subcutaneous tissue
and behave more like endogenous
insulin than regular insulin. When
we eat, our bodies begin producing insulin within 5 to 15 minutes
of the first bite. Within 1 to 2
hours, endogenous insulin and
postprandial glucose reach peak
concentrations; within 3 to 4 hours,
they return to baseline. Similarly,
rapid-acting insulin has an onset of
5 to 15 minutes, a peak time of 1
to 2 hours, and a duration of 3 to 4
hours. You must give it within 5 to
15 minutes of the first bite to
match the peak postprandial blood
glucose level.
An advantage of rapid-acting insulin over regular insulin as a
mealtime insulin is that it can be
given before or after the first bite.
This offers some scheduling flexi10
Timing insulin
reduce the risk of
periprandial hypoglycemia
and subsequent blood
glucose variability.
bility and the ability to assess how
much the patient eats before giving
insulin. In Mr. Browns case, he has
eaten part of his meal before you
arrive with his insulin dose. Some
nurses may be tempted to withhold
his insulin for fear of inducing hypoglycemia, but withholding this
dose would put Mr. Brown in danger of hyperglycemia. Rapid-acting
insulin analogs can be given safely
up to 15 minutes after the first bite,
avoiding hypoglycemia.
You may not always know how
a patient will respond to a given
insulin dose, as with patients who
have poor renal function or complex diabetes states (brittle diabetes). This can be challenging at
mealtimes, when many factors determine patient response, including
the insulin type, purpose of insulin,
current blood glucose level, disease
state, renal function, and nutritional
status.
Answers to the questions you
may have about giving insulin at
mealtimes may not always be
straightforward. Mrs. Smith, for instance, has a long history of type 1
diabetes and a serum creatinine
level of 1.6 mg/dL. Because of her
poor nutritional status, impaired renal function, and diabetes state,

her blood glucose response to insulin is less predictable. She needs
close evaluation for each mealtime
insulin dose. If you think a dose
may need to be omitted or
changed, consider all relevant factors to determine the proper course
of action, and make recommendations to the attending physician.
Dont take insulin therapy for

granted
Some nurses may take insulin administration for granted because
they perform it every day. But
oversimplifying this task can put
patients at risk for adverse outcomes, such as hyper- or hypoglycemia. Insulin administration involves a complex decision-making
process, and clinicians need to collect and evaluate a great deal of
data to reduce the risk of adverse
outcomes. By considering all relevant patient data, you can reduce
the likelihood of an insulin-related
adverse outcome.
O
Selected references
American Diabetes Association. Standards of
medical care in diabetes2013. Diabetes
Care. 2013;36 Suppl 1:S11-66.
Cobry E, McFann K, Messer L, et al. Timing
of meal insulin boluses to achieve optimal
postprandial glycemic control in patients
with type 1 diabetes. Diabetes Technol Ther.
2010;12(3):173-7.
Freeland B, Penprase BB, Anthony M.
Nursing practice patterns: timing of insulin
administration and glucose monitoring in
the hospital. Diabetes Educ. 2011;37(3):35762.
Freeman JS. Insulin analog therapy: improving the match with physiologic insulin secretion. J Am Osteopath Assoc. 2009:109(1):26-36.
Umpierrez GE, Smiley D, Zisman A, et al.
Randomized study of basal-bolus insulin
therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial).
Diabetes Care. 2007;30(9):2181-6.
Julie S. Lampe is a diabetes clinical nurse specialist

at the Orlando Regional Medical Center, Orlando
Health, in Orlando, Florida. (Names in scenarios are
fictitious.)
Strictly Clinical
RAPID RESPONSE
A swift, decisive
response to GI bleeding
Coffee-ground emesis tips off caregivers to acute upper GI bleeding.
By Ira Gene Reynolds, MSN, RN
DAVID SANDERSON, age 63, is admitted to the orthopedic unit after surgical repair of a compound
fracture of the right radius. His medical history includes cholecystectomy and depression. Current
medications are paroxetine and occasional acetaminophen for headache. Before surgery, he received I.V. hydromorphone and ketorolac to reduce
inflammation and help control pain. He also received 1 G cefazolin I.V.
After surgery, he continues on I.V. antibiotics and
is started on I.V. morphine or oral acetaminophen/
oxycodone (Percocet), plus I.V. ketorolac for pain
control. He continues to receive paroxetine.
History and assessment hints

On the third day after surgery, as he is about to be discharged, Mr. Sanderson suddenly becomes lightheaded,
dizzy, and nauseated while getting dressed. He vomits a
moderate amount of coffee-ground emesis. You find him
lying on the bed, pale, lightheaded, and somewhat disoriented. His vital signs are blood pressure 68/32 mm
Hg, heart rate 136 beats/minute (bpm), respiratory rate
24 breaths/minute, and oxygen (O2) saturation 93%.
While you call the rapid response team (RRT) and the
physician, the charge nurse administers 2 L oxygen via
nasal cannula and starts an 18G I.V. line. Then you hang
a bag of normal saline solution. Mr. Sanderson vomits a
large amount of emesis; this time, it includes frank blood.
On the scene
The RRT arrives, starts another I.V. line, hangs another
bag of normal saline solution, and orders a complete
blood count and chemistry panel. Now Mr. Sandersons
vital signs are blood pressure 82/44 mm Hg, heart rate
124 bpm, respiratory rate 20 breaths/minute, and O2
saturation 96%. He seems more alert. You continue to
monitor for signs and symptoms of worsening GI bleeding, such as another drop in blood pressure, an increased heart rate, and loss of consciousness.
The physician orders a liver panel and coagulation
studies, a 1-L bolus of normal saline solution followed by
a continuous infusion at 150 mL/hour, one dose each of
ondansetron and pantoprozole I.V., and a nasogastric tube
to avoid aspiration from recurrent nausea and vomiting.
Outcome
You prepare Mr. Sanderson for an emergency endoscopy to assess the extent of his GI bleeding. Endoscopy reveals a small bleeding ulcer near the duodenum. The physician obtains a biopsy and cauterizes
the bleeding; the patient recovers in the endoscopy
lab before returning to the nursing unit. He is monitored for additional bleeding for several days and is
being considered for discharge.
Education and follow-up

Acute upper GI bleeding requires quick intervention.
The most common signs and symptoms are hematemesis
(vomiting of blood or coffee-ground-like material), and
melena (black, tarry stools). In contrast, lower GI tract
bleeding is more closely associated with hematochezia
(red or maroon blood in the stool). Depending on
bleeding extent and severity, the patient may have either
a significant blood pressure reduction and increased
heart rate, or just minor alterations in these vital signs.
Causes of GI bleeding vary and generally are classified
by anatomic and pathophysiologic factors. More common classifications include bleeds from ulcerations or
erosion, portal hypertension, vascular malformations,
trauma or surgery, and tumors.
A wide range of drugs can cause ulcers and erosion
of the stomach lining, leading to GI bleeding. Using
certain concurrent medications increases the risk of GI
bleeding, too. The combination of ketorolac and paroxetine increased Mr. Sanderson's risk.
Patients who have a GI bleed stand a higher chance of
recurrence. Before discharge, you teach Mr. Sanderson
how to recognize signs and symptoms of GI bleeding and
what to do if these occur. You advise him to be aware that
his antidepressant medication combined with certain other
drugs can raise his risk. You stress the importance of sharing his drug information with all healthcare professionals. O
Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.
Ira Gene Reynolds is a staff nurse on the medical/oncology unit at Utah Valley
Regional Medical Center in Provo.
November 2014
11
Practice Matters
THE HUMAN SIDE
OF
P AT I E N T S A F E T Y
Managing our fears to

improve patient safety
By Susan Tocco, MSN, CNS, CNRN, CCNS, and James DeFontes, MD
AN
ESSENTIAL ELEMENT of professional practice,

nurse advocacy for patient safety is embedded in the
American Nurses Associations Code of Ethics. Yet evidence suggests nurses and other healthcare professionals dont always speak up with their patient-safety
concerns. In 2005, the Silent Treatment Study involving
1,700 nurses, physicians, and other healthcare professionals found that 84% observed fellow clinicians take
dangerous shortcuts but fewer than 10% confronted
these individuals about their actions.
Why are so few of us willing to speak up on our patients behalf? Amy C. Edmonson, a social psychologist and professor of leadership and
management at Harvard, studied the
fears of people working in groups.
From her observations in health
care and other industries, she
found employees believe others in the workplace are
constantly evaluating them.
For workers in all settings,
protecting ones image is
important. The added
stress of maintaining
ones image while under a perceived microscope of scrutiny at
work is the main reason clinicians dont
speak up; they feel its
not safe to do so.
Edmonson uses the
term psychological safety to describe an individuals perception that
the practice environment is conducive to taking a potentially imagethreatening risk. In
psychologically safe environments, healthcare professionals believe they wont suffer adverse consequences if they report a mistake or ask
for help, education, or feedback. In environments that lack psychological safety, on the other hand,
workers tend to keep their concerns to themselves.
12
Leaders must develop a structured

process for team learning and
communication.
Fears that promote silence
Edmonson identified four distinct fears that promote
silencefear of being perceived as ignorant, incompetent, negative, or disruptive. Lets examine how each
of these fears can affect patient safety.
Fear of being perceived as ignorant
Fear of being perceived as ignorant makes a person less inclined to ask questions. For instance, a nurse who floats to a different
unit may lack recent experience accessing
central venous catheters. Shes afraid to
ask for assistance because she thinks
nurses on the unit will
look down on her for
not understanding
this seemingly basic skill. So she accesses a patients
catheter on her
own and unknowingly
violates sterile technique.
As a result, the patient develops a bloodstream infection.
Fear of being viewed as
incompetent
Fear of being viewed as incompetent
makes a person less likely to report
a mistake or near-miss. Suppose a
nurse narrowly avoids giving a medication to the wrong patient because she is
distracted by a phone call from the lab.
She fails to report this near-miss because
she fears her manager and peers will think
shes incompetent.
Failing to report events and near-misses is particularly harmful because it prevents organizational
learning. Learning from this event could have led
to systematic changes to limit nurse distractions during
medication administration, which

might prevent future medication errors from harming patients.
Fear of being seen as negative
Fear of being seen as negative can
stop someone from giving accurate
individual and team performance appraisals. Say, for example, a nurse
manager conducts a meeting with her
staff. She reports that two patient
falls occurred in the past week, and
she seeks feedback from the team on
how these falls could have been prevented. One of the units newer nurses witnessed significant delays in answering patient call bells but was
afraid to speak up because she
feared the team would think shes
negative. If she had spoken up,
strategies to improve call-bell responsiveness could have been addressed,
helping to prevent future falls.
Structured processes used in healthcare settings

Briefings, debriefings, and time-outs promote communication and feedback in
healthcare settings.
Surgical settings
Before a briefing in the operating room, the first names and roles of each team
member should be written on a whiteboard. During the briefing, the surgeon discusses critical steps and problems that may be encountered, asks team members
how theyd respond to a specific problem should it occur, and encourages them
to voice concerns they may have during the case. The anesthesiologist discusses
relevant patient comorbidities, availability of and potential need for blood products, and interventions to prevent complications. Nursing staff discuss relevant issues, such as sterility, availability of instruments, need for special equipment, and
a plan for breaks. During the time-out, critical information about patient identification, surgical site, procedure, antibiotic selection and timing, and display of
necessary imaging is reviewed.
After the procedure, debriefing includes verifying equipment counts, specimen labeling, and equipment issues that need to be addressed. The team reviews key concerns for the patients continued care and discusses what went
well, any challenges that arose, and what should be done differently the next
time as a result of learning from this case. The World Health Organizations Surgical
Safety Checklist includes essential elements of surgical briefings, time-outs, and
debriefings. (Visit www.who.int/patientsafety/safesurgery/tools_resources/
SSSL_Checklist_finalJun08.pdf?ua=1.)
Fear of being seen as disruptive

Nursing units
During a time-out in the operating
On the nursing unit, a briefing should occur at the start of the shift. Any new or
float team members are introduced and welcomed. Patients at risk for instabiliroom, a nurse isnt sure if the paty are discussed. Patients at high risk for falls and pressure ulcers are reviewed,
tients correct hip was marked for
and the team discusses the plan for toileting and ensuring skin integrity. The
surgery. She considers speaking up,
charge
nurse or nurse manager encourages the team to ask questions and report
but the orthopedic surgeon is runproblems or near-misses immediately.
ning behind and has encouraged
At the end of the shift, the debriefing includes discussion of the high points of
everyone to be as efficient as possithe day as well as challenges that arose (such as falls, medication errors, patient
ble so he can finish all of his cases
transfers to higher levels of care, and near-miss events). Finally, the team discussbefore his sons soccer game starts.
es changes that need to be made based on learning from the shift.
The nurse keeps her concern to herself, fearing shell be seen as disrupthe team. Traditional access barriers, including the
tive if she speaks up. If she had spoken up, the paneed to go through assistants or residents, should be
tient could have avoided wrong-site surgery.
removed. This increases the likelihood of team memCommunication failure: A leading cause of patient bers approaching the leader with questions or conharm
cerns and speaking up immediately as patient-care
Overwhelming evidence points to communication failissues arise.
ure as a leading cause of patient harm. To address the
When confronted with questions or disclosure of
communication problem, a foundation of psychologimistakes or errors, the leader must make a conscious
cal safety must be achieved. Laying this foundation reeffort to treat team members with respect to reinforce
quires a deliberate process on the part of team memtheir willingness to share information. She must clearly
bers at all levels of the organization.
convey shes receptive to hearing bad news. Also, she
can acknowledge her own humanness by telling her
Transforming power-based relationships
team she needs them to speak up because she knows
Presence of someone with higher status in the organishe may overlook certain things. She can seek feedzation intensifies the perceived risks of speaking up.
back directly from team members at all levels to show
Team leaders are responsible for transforming these
she wants their input.
power-based relationships and flattening the hierarchy.
When encouraging participation, the leader must esTo influence psychological safety in a positive way,
pecially encourage junior or lower-status team memleaders must make sure theyre directly accessible to
bers to speak up, as by asking junior team members
November 2014
13
for their input and calling on them

before calling on senior team members. In addition, she must manage
overpowering behaviors of higher-status team members. Leaders must not
tolerate inappropriate, demeaning,
bullying, or disruptive behaviors by
any team member.
Structured processes for learning

and communication
How staff nurses can promote psychological safety

Leaders arent the only team members responsible for creating a psychologically safe environment. Every nurse is accountable for promoting a safe environment, regardless of his or her role.
Psychological threats can occur in both the horizontal and vertical hierarchies of teams. Reflect on your personal experience with other nurses:
How comfortable were you speaking up as a student nurse? A graduate
nurse? A float nurse?
Have you witnessed colleagues belittle fellow nurses, clinical technicians,
or residents? Did you intervene when you witnessed such behavior?
Do patients and their families feel its safe to ask questions of you and your
nurse colleagues? How do you respond to their assertive questions?
To succeed in creating a psychologically safe practice environment,

healthcare leaders must develop
structured processes for team learning and communication. The healthcare industry has
taken particular notice of airline safety improvements
over the last few decades. The Commercial Aviation
Safety Team was founded in the late 1990s in response to multiple serious events; 10 years later, the
rate of commercial air travel fatalities had dropped
83%. Like the healthcare industry,
airlines have highly skilled employees who must function effectively as
team members to ensure safe performance. Structured, open communication is a key driver of this safety
improvement.
In health care, the main purpose
of promoting open communication
and feedback is to generate learning
to improve the safety and quality of
patient care. The leader must create
a structure to support this process.
One such structure involves briefings
and debriefings. Briefings have been
used successfully in many high-risk
industries, including aviation, to
unite the team in a shared framework or mental model for performance. The groups task defines the nature of the briefings and debriefings. (See Structured processes used
in healthcare settings.)
noses; this message can make them insecure about presenting their assessment results, causing them to paint
a broad picture of the patients condition when communicating with physicians. The physician on the receiving end of this lengthy message becomes impatient,
waiting for the nurse to just ask for what she wants.
The SBAR (Situation, Background,
Assessment, Recommendation) tool
can provide a common structure for
communication. When SBAR is used
as intended, the nurse is asked to suggest a diagnosis and ask for a specific
treatment or action from the physician. But many nurses are uncomfortable doing this and havent been
taught to think and communicate
within this structure. Role-playing and
practice with case studies can make
them more comfortable. Faculty at
some nursing schools already are
working to embed this communication
style in the new generation of nurses.
Because of the entrenched healthcare hierarchy, nurses tend to communicate deferentially and indirectly
when they speak up about patient-safety concerns.
How can leaders pave the way for team members to
assert their concerns effectively? One organization has
empowered nurses to bypass SBAR in critical obstetric
situations simply by stating, I need you to come now
and evaluate this patient. Physicians understand
theyre accountable for responding promptly every
time. Another example of mutually agreed-upon critical language derives from United Airlines safety program, called CUSan acronym for Im Concerned, Im
Uncomfortable, This is unSafe.
For critical language to be effective, leaders must
ensure all team members understand it, grasp its intent, and adopt a culture that enables immediate actions to address patient-safety concerns when this
Nurses and physicians

are taught to
communicate in
markedly different ways,

which can cause or
contribute to reluctance
to speak up about
safety concerns.
Providing a common structure for

communication
For teams to communicate safely and effectively within
structured processes, a common communication style
and common assertion techniques must be established.
Nurses and physicians are taught to communicate in
markedly different ways, which can cause or contribute
to reluctance to speak up about safety concerns.
Physicians are taught to be concise and get to the point
quickly. Nurses, on the other hand, are reminded during their educational process that they cant make diag14
language is used. (See How staff nurses can promote

psychological safety.)
Implementing new communication models

Implementing these new communication models can be
challenging. Formalized education addressing effective
communication has been lacking. Many clinicians lack
the skills they need to engage in crucial conversations
in their personal livesyet we expect them to draw on
such skills when patient safety is at stake.
Other factorsgender, age, race, religion, culture,
tenure, education, and cliquesalso can threaten team
communication. Leaders must have robust administrative support to ensure the success of this new communication framework. Organizational development teams
can be crucial in creating classes and promoting roleplay and other creative interactive learning strategies
to help launch new communication models.
Emerging from the cloak of silence

In a broad sense, all healthcare professionals report to
the patient. If we were all players on a basketball
team and our communication and teamwork were
poor, wed lose games and our coach would be fired.
When we exhibit similar shortcomings in our healthcare teams, the patient suffers harm. Embracing this
shared mental model of accountability to the patient is

the first step in laying the foundation for psychological
safety. This model empowers nurses to emerge from
the cloak of silence and take an active, professional
O
role in keeping patients safe.
Selected references
CAST: The Commercial Aviation Safety Team. www.cast-safety.org.
Accessed March 14, 2014.
Edmonson A. Managing the risk of learning: Psychological safety in
work teams. In: West MA, Tjosvold D, Smith KG, eds. International
Handbook of Organizational Teamwork and Cooperative Working.
London: Blackwell; 2003.
Leonard M, Graham S, Bonacum D. The human factor: the critical
importance of effective teamwork and communication in providing
safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-i90.
Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings
and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.
Maxfield D, Grenny J, Lavandero R, Groah L. The silent treatment:
Why safety tools and checklists arent enough to save lives; 2011.
www.silenttreatmentstudy.com/. Accessed March 11, 2014.
World Alliance for Patient Safety. WHO surgical safety checklist and
implementation manual. 2008. www.who.int/patientsafety/
safesurgery/ss_checklist/en/index.html. Accessed March 11, 2014.
Susan Tocco is the director of operational effectiveness at Orlando Health in

Florida. James DeFontes is the assistant executive medical director at KaiserPermanente in Pasadena, California.
Get even more American Nurse Today!

Visit our brand new website at www.AmericanNurseToday.com
and join our growing online community.
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Enhanced article search Videos Health and wellness information
November 2014
15
Career Sphere
STOP: A strategy for dealing

with difficult conversations
By Kathleen Pagana, PhD, RN
MONICA IS LATE for work again. June has body

odor. Brian doesnt comply with the hospitals cell-phone policy.
As a nurse manager, you know you
need to do something. Are you
avoiding the tough conversations
required to deal with these
issues? Whats holding you
back from communicating
openly with your staff? This article can help you open up your
communication style and stop
avoiding tough conversations.
(See Topics that can make for
tough conversations.)
Preparing for difficult
conversations
As with anything, preparation is important. Before confronting someone
about a prickly topic, ask yourself:
Whats the problem?
How do I feel about it?
What do I want to be different?
Suppose you need to confront a staff nurse
who has been bullying new nurse graduates. Here
are the key questions to ask yourself beforehand,
along with possible answers:
1. Whats the problem? Answer: A staff nurse is bullying new graduates, who arent getting the support
they need as they transition to the work environment.
2. How do I feel about it? Answer: I am angry and
frustrated. If this keeps up, I will lose staff. Theres
also the issue of patient safety if new nurses cant
seek help.
3. What do I want to be different? Answer: I want the
Topics that can make for tough

conversations
16
Asking for a promotion

Bullying and incivility
Discrimination
Lack of teamwork
Noncompliance with policies

Poor hygiene
Tardiness
Sexual harassment
This four-step process guides

you through prickly
topics with your staff.
bullying to stop. I want a positive work
environment with collaboration and cooperation.
Putting STOP to work

The STOP strategy helps guide you
through difficult conversations. Here are
the key components:
State the situation or problem.
Tell the personwhat you want.
Offer an opportunity
to respond.
Provide closure (review, summary, or thanks).
State the situation or problem
Sharing facts increases your confidence: for example, This is the third
time this week. But be sure to separate the behavior from the person doing it. Rather than
labeling the person lazy or sexist, describe the behavior. For example, Ive noticed that.
Share your feelings: I feel or When you do A, I
feel B. Avoid saying, You make me feel.
Sometimes its hard to start a difficult conversation.
Here are some tentative beginnings:
Perhaps youre not aware
Im beginning to wonder
I need your help with something.
Tell the person what you want
Dont expect people to know what you want unless you
tell them. Suppose your college-age son is home for a
weekend and running the washing machine and dryer
outside your bedroom at midnight. If you tell him his
laundry chores are interrupting your sleep, he may think
he should stop at, say, 10 P.M. So be specific: Id like
you to be done with your laundry by 8 P.M.
Reaping the benefits

The benefits of handling tough conversations include:
better workplace environment
improved staff retention
personal growth
enhanced working relationships
greater patient safety.
Offer an opportunity to respond

Make this a two-way conversation. Otherwise, youre
just delivering criticism. Invite the other person to respond: Do you agree? or Can we work something
out? or What do you think about this? The persons
response provides an opportunity to evaluate how the
conversation is going.
Provide closure
To prevent rambling and repetition, review or summarize the conversation. For instance, thank the person
for meeting with you: Thanks for getting together to
discuss this important issue. I hope you can improve.
Wed hate to lose you. Youre an excellent clinician.
Using STOP for common workplace problems

Sometimes the best way to learn something is to see
examples in common workplace situations. Review the
six examples below.
Problem: Tardiness
S: Monday and Tuesday, you arrived 20 minutes
late for work.
T: I want you to be here at 6:45 A.M. (Dont say
You have to be punctual.)
O: Can we agree to this?
P: Thanks. This will help us work better together.
Problem: Body odor
S: I need to talk to you about a personal issue,
and theres no way to make it easy for either
one of us. Ive noticed you often have body
odor that you may not be aware of. It could
be your personal hygiene, diet, or a physical
problem.
T: I hope youll check this out and do something
about it. Im sure you can improve this situation.
O: Am I making sense?
P: Thanks for meeting with me.
Problem: Sexual harassment
S: Perhaps youre unaware that when you talk to
me, your eyes move up and down my body.
Sometimes, you put your hand on my shoulder
or around my waist. These behaviors make me
uncomfortable.
T: I want them to stop.

P: Thanks. That will help us work together better.
Problem: Incivility
S: The way you told me the staff thinks Im an idiot has me worried. You smiled when you said
it. I wonder if you take pleasure in giving me
negative feedback.
T: Id like to have a better working relationship
with you. Lets talk about a different way to
speak to one another.
O: So that we can resolve this issue, whats your
take on the situation?
P: Thanks for meeting with me. I want us to
work together better.
Problem: Lack of teamwork
S: Working on this project takes a lot of teamwork. Youve been late with your last two
deadlines. Im frustrated being held up and
having to catch up.
T: I want you to have your work done on time.
P: Thanks. This is a very important project.
Problem: Dress-code violation
S: I see you have a new eyebrow piercing. Its a
violation of our dress code.
T: Please remove it during work hours.
O: Do you have any other questions about the
dress code?
P: Thanks. See you later at the staff meeting.
Getting started
Fear can hold us back from difficult conversations. Fear
is based on the importance of the subject and of the
relationship. Dealing with a store clerk about a damaged product is easier than dealing with a coworker
about body odor. Build your confidence as you practice the STOP strategy in situations with a lower fear
factor.
Knowing how to handle tough discussions yields
many benefits. (See Reaping the benefits.) The STOP
strategy is simple and easy to use. It can improve your
communication as you gain confidence and stop avoidO
ing difficult conversations.
Kathleen D. Pagana is a keynote speaker and professor emeritus at Lycoming
College in Williamsport, Pennsylvania. She is the author of The Nurses
Communication Advantage and The Nurses Etiquette Advantage. She is also the
coauthor of Mosbys Diagnostic and Laboratory Test Reference, 11th ed. To contact
her, visit www.KathleenPagana.com.
November 2014
17
Mind/Body/Spirit
GET
H E A LT H Y !
What to do when someone

pushes your buttons
By Laura L. Barry, MBA, MMsc, and Maureen Sirois, MSN, RN, CEN, ANP
WHY
IS IT that some things dont bother us, while

other things catapult us from an emotional 0 to 60 mph
in a heartbeat? We all know what it feels like when
someone says or does something that gets our juices
flowing. We feel it in our bodies, emotions, and mood.
We have an overwhelming urge to react. We may express it in words at the time or take our frustrations out
later on someone else. It just doesnt feel good. We
want to explode, set the record straight.
If the button pusher is your boss, you may internalize your reaction. Your mind is still buzzing with what
youd like to say, but youre not likely to express those
angry words to a superior at work. On the other hand,
if the button pusher is a significant other, colleague,
child, or friend, you may choose not to hide your feelings. Perhaps youll have a minor explosion and let
them know how you feel.
But what are you really reacting to? You might think
its the situation at hand, but it isnt. Instead, youre reacting to something about that situation. Maybe it reminds you of a past emotional wound. Perhaps youre
interpreting it in a certain way. Whatever it is, its usually something deeper. When someone pushes a button, theres always more to the story than just the current situation.
Having our buttons pushed is uncomfortable, and
wed prefer to avoid it. But the truth is, we cant avoid
it. It will happen again and again, each time building
on the last. So instead of trying to avoid it, try to embrace it.
earthed them and shone light on them?

To look at a situation honestly and gently requires
compassion toward yourself. Getting to whats beneath
the issue at hand or the surface emotion is a growth
opportunity. It gives you the chance to look at the situation differently. It means youve opened yourself up
to learning and healing.
Having your buttons pushed

can help you find invisible
cords of connection that need
your attention.
Pause and dig deeper

The next time someone pushes one of your buttons,
dont react instinctively. Instead, pause for a moment
and dig deeper to try to find the cause of your reactionsomething beneath the surface that needs to be
excavated and studied gently.
Often, when a button gets pushed, we blame the
button pusher for how it makes us feelfor what that
person did to us to cause this reaction. We externalize
the issue and dont take responsibility or own what
our bodies are telling us. (See Button pusher as
teacher.)
But what if we looked at our buttons in a whole
new light? Instead of hiding them and never knowing
when and where they will be pushed, what if we un18
Unearthing unresolved wounds

Recently, a most tender button of
mine was pushed; someone made a
comment that was unexpected and
unappreciated. Thats it. But it really
bothered me. I immediately thought,
This person always does this to
Its hard to like someone who pushes your buttons. But what if you view this permenever has anything nice to say.
son as your teachersomeone whose role is to help you dig deeper to find the
This feels humiliating.
cords that keep you tethered to hurt, disappointment, fear, or anger? When you
I restrained myself from respondpause to view this other person as your teacher, you shift and soften. You step
ing (although Im sure my body lanout of the victim role. In this softness, healing can begin.
guage and facial expression spoke
Pausing gives you the space and opportunity to see things differently, to operate out of lovenot anger, the past, or fear. Instead, youre operating out of
volumes). Instead, I paused, and once
love for yourself. As you look on the other as your teacher, you may feel gratitude
I was away from that person, I did
for
that personor perhaps even love.
some deep breathing to release my
feelings. I thought about what was
said and how I felt. During that
over because when we complete something, we acpause, I realized my body was telling me there was
knowledge
a finality, sometimes with a sense of acmore to this than just the unappreciated comment. I recomplishment,
and move to the next door thats openalized the intensity of my feeling was out of proportion
ing.
We
complete
grade school and move on to high
to the comment.
school.
We
complete
an exam and become certified in
As I let myself sit with this disturbing emotion, I
a
field.
We
complete
grocery
shopping and go home to
asked myself, Why does this bother me? I realized it
make
dinner.
Complete
removes
judgment.
bothered me because it made me feel I hadnt been
The
invisible
cords
of
connection
can be a drain if
heard. So what does that mean and where else in my
they
are
cords
of
fear,
anger,
hurt,
resentment
or if they
life do I feel I havent been heard? As I continued to
carry
a
should-have
implication.
Those
cords
need to
dig, I remembered many of the other times Id felt this
be
cutwith
kindnessby
a
willingness
to
look
deepway. I realized that not being heard is an old wound
er
into
our
reactions.
Theyre
energy
drains.
When
the
coming from my childhood in a big family. To me, not
function
of
the
umbilical
cord
is
complete,
it
must
be
being heard means not being loved or cared aboutor
cut for the greatest good of mother and child. So, too,
at least thats how I interpreted it.
with
past experiences or relationships that are comThe current issue had brought up those old, unreplete.
For the greatest good of all involved, the cord
solved hurts and beliefs from childhood so they could
that
no
longer serves a loving, peaceful purpose must
be healed. As an adult, I can look back at that childbe
cut.
Only
cords of love, compassion, peace, and joy
hood me who was hurt and tend to the wound so it
can sustain.
doesnt have to keep resurfacing at unpredictable
times. And when it does arise, I can lovingly say, Oh,
Pause, digest, reflect, and respond
its you again. I can pause, honor my feelings from
Having your buttons pushed can be a wonderful way
the past, and give myself permission to feel what Im
to find out what invisible cords of connection need
feeling. I can remind myself that this is an old wound
attention. Through a willingness to excavate the unsurfacing now for healing.
derlying cause of our reaction, we begin the healing
This perspective helps me realize the experience is
process.
happening for me, not to me. That shift in my perspecSo for today, I will notice and be grateful when
tive allows room for investigation, curiosity, and most
someone pushes my buttons. I will pause, digest, reimportantly, healing. When something happens for me,
flect, and respond. Knowing its being done for me and
it implies its good; when it happens to me, Im a vicnot to me, Ill be grateful for the growth and awareness
tim. For me comes with intention and purpose. To
it can bring, grateful that my body speaks to me.
me comes with blame and hurt.
And you? What buttons will be pushed for you toCords of connection
day? When they are pushed, will you pause, digest, reIn a sense, invisible hollow cords connect us to every
flect, and dig deep to find the cause of your reaction?
O
experience and relationship from our past. Even when
Will you cut the invisible cord?
an experience or relationship is complete (perhaps
youd describe it as over), those invisible cords of
Laura L. Barry is business consultant and leadership coach. Maureen Sirois is a
nurse consultant on health and wellness.
connection remain. I use the word complete rather than
Button pusher as teacher
November 2013
19
Leading the Way
What you can learn from

failure
By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
RACHEL is an experienced critical care nurse who

prides herself on her abilities. During her current
travel assignment, several nurses invite her to take
the CCRN exam with them. She has been thinking
about taking the exam and looks forward to getting
to know the nurses at her assigned hospital better,
so she agrees. Despite taking an online review course
and spending hours
studying with her
coworkers, she fails the
exam. Shes extremely
upset, in part because
she's afraid they will
think less of her as a
nurse, making her remaining time in her assignment more difficult.
Most of us have had
the experience of failing
to achieve a goal, making a poor judgment
call, or being overlooked
for a coveted position.
Sometimes our failures
are public. More often,
theyre private and we
never discuss them with
anyone. On the other
hand, we celebrate our
successes. Similarly, most
journal articles focus on
whats working in organizations; few focus on
initiatives that failed.
Youve probably heard
the famous line from
the movie Apollo 13:
Failure is not an option. Ive seen it as a
tagline in many e-mail signatures.
Although few professionals openly discuss their
failures, failure is part of the professional experience.
According to author and resilience expert Martin
Seligman, PhD, failure is an inevitable part of work.
Along with dashed romances, work failure is one of
20
Find out why your failures can

serve as excellent teachers.
lifes most common traumas. If you never fail, Seligman believes, youre probably not taking risks that
will lead to your professional growth or organizational innovation.
Reflecting on failures
and learning from them
are essential.
Handling failure
We each respond to failure in different ways,
depending on our life experiences. Amy Edmondson, a business expert on
the topic of failure, notes
that were programmed
from an early age to
think failure is bad. Conversely, we learn success
has a reward attached
to it, whereas failure
comes with some type of
punishment.
The emotional consequences of personal failure can be hard to overcome. Like Rachel, many
professionals are perfectionists with high expectations for themselves.
When they fail, their
harsh inner critic may
tell them theyre not
smart enough. This can
lead to negative self-talk and fear theyll lose colleagues respect. For instance, because she failed the
CCRN exam, Rachel may mentally discard all her positive contributions to her unit. Other people may take
a different approach when they fail, blaming others
rather than admitting their own role.
Systems failure
But not all failures are equal. Preventable failures, such as medication errors, are viewed
negativelybut many organizations are moving to a culture that deemphasizes individual
blame. In complex organizations and settings,
such as busy emergency departments, systems failure is a perpetual risk. In these settings, root cause analysis is a good process
for identifying and correcting systems failures.
Key questions to ask yourself

After a failure, you can move forward by asking yourself these questions:
Reflecting on failures
Individuals need to take professional risks to
enhance their careers. But to do this, you
must reflect on your failures, analyze why
they happened, and learn how to use them
to help yourself and others. To overcome
failure, assess the problem objectively before
choosing a path to overcome it. (See Key
questions to ask yourself.)
What happened? Why did it happen? Take a step back and look at
the big picture. Did you miss key signs that failure might occur?
Could you, or should you, have done things differently? Avoid blaming others, focusing instead on your own role and responsibility.
What are the consequences of the failure? Things rarely are as
detrimental as you fear, if you let yourself develop a better perspective on the event. Get past the idea that failure is about you
personally. Failure is an event in time; it shouldnt define you as a
person, no matter how serious it was.
What can I learn from the situation? Failure always brings an opportunity to learn significant lessons. Analyze how you reacted to
the failure and what types of support you received from others.
Use the knowledge and skills youve gained from the situation in
a positive way.
How can I apply the lessons Ive learned in the future? Develop a
positive attitude toward failure. Know that feelings of personal failure eventually will pass and youll probably come out of the situation having learned many valuable lessons. Also, reflect on how
you might use this failure to help others. Professionals who share
their failures can provide powerful lessons learned for those they
mentor.
Building resilience
How well we recover and grow from failure
depends partly on our resilience. Potentially,
Rachel could go from being extremely sad
about failing the exam to becoming depressed, to experiencing a paralyzing fear of
retaking it. Or she could bounce back after a brief period of malaise with new determination to pass it.
From working with military veterans, Seligman
found optimism is the key to resilience in the face of
failureoptimism that whatever the failure is, its temporary, local, and changeable. Too often, we let our
minds make up a story about the failure and we tell
ourselves this story over and over. But if you can control your thoughts about failure, you can control your
attitude. Resilience means keeping positive thoughts;
staying aware of your individual gifts, talents, and
strengths; and encouraging yourself to keep moving
forward.
Recovering and moving forward

Our failures can become some of our best teachers if
we pay attention to and learn from them. They can
give us the courage to confront our own and others
imperfections and to accept failure as inevitable in
todays complex work organizations. Most successful
people acknowledge theyve learned more from their
failures than their successes. J.K. Rowling, author of
the Harry Potter book series, said in a Harvard commencement address, It is impossible to live without
failing at something, unless you live so cautiously that
you might as well not have lived at all. Ms. Rowling
knows about failure: She was a single, unemployed
mother who received 12 rejections before a publisher
accepted her first Harry Potter book.
Some people fear failure so much that they never
put themselves in situations in which they could fail.
But this sets a low ceiling on their prospects for professional success. Fear of failure is one of the strongest
forces keeping people below their potential. In the
bestseller The 4-Hour Workweek: Escape 9-5, Live
Anywhere, and Join the New Rich, author Timothy
Ferriss advises readers to ask themselves what would
happen if they chased their dreams and fell flat on
their faces. He suggests the recovery time would be
far shorter than we think.
Wise professionals recognize that if you dont take
risks, you lose out on opportunities. We hear so much
these days about the virtues of being positive and successful. But we need to remember that our negative
experiencesincluding those that lead to failurealso
O
play an important role in finding success.
Selected references
Edmondson AC. Strategies for learning from failure. Harvard Bus
Rev. 2011 Apr;89(4):48-55.
Ferriss T. The 4-Hour Workweek: Escape 9-5, Live Anywhere, and
Join the New Rich. (Exp upd ed.) New York, NY: Crown Archetype;
2009.
Fralic MA. Thoughts on failure: three questions to ask. Nurs Leader.
2011;9(5):5, 60.
Seligman MEP. Building resilience. Harvard Bus Rev. 2011 Apr;89
(4):100-6.
Sherman R. Learning from failure. January 23, 2012. www.emergingrnleader.com/tag/learning-from-failure. Accessed May 1, 2012.
Rose O. Sherman is an associate professor of nursing and director of the Nursing

Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic
University in Boca Raton, Florida.
November 2014
21

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November 2014 Special Edition

BEST OF THE BEST

Editorial Advisory Board

Gail Pisarcik Lenehan, EdD, RN, FAEN, FAAN

American Nurse Today Best of the Best

American Nurse Today is the official journal of the

November 2014 Special Edition

Dispelling pain myths

Beware of oversimplifying mealtime insulin dosing for

By Lora McGuire and Pam Bolyanatz

A swift, decisive response to GI bleeding

Managing our fears to improve patient outcomes

Stop: A strategy for dealing with difficult conversations

What to do when someone pushes your buttons

Leading the Way

What you can learn from failure

American Nurse Today Best of the Best

Alcohol screening and brief intervention: A clinical solution

OR EXCESSIVE alcohol use is common, expensive, and underrecognized as a significant public

Understanding how much drinking is too much

Drinking too much includes

Source: CDC. www.cdc.gov/vitalsigns/alcohol-screening-counseling/infographic.html

American Nurse Today Best of the Best

taking certain prescription drugs, those who have

What can be done?

on the results of this discussion, help the patient

How can nurses intervene?

What is alcohol screening and brief intervention?

A number of excellent resources are readily available

Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.

Nancy E. Cheal is a research health scientist, Lela McKnight-Eily is an

American Nurse Today Best of the Best

Read up on the latest evidence-based best practices

UNLESS MANAGED aggressively,

Pain myth #1: Standard

American Nurse Today Best of the Best

aging (MRI) scan reveals a new disc

er-than-standard analgesic dosages

participate in physical therapy. She

Pain myth #2: Older adults

shouldnt receive chronic opioid

Common nonopioid drugs used for acute pain

education on the purpose of pain

balizes to her husband that she will

The dangers of labeling patients

Best practices in pain

American Nurse Today Best of the Best

Common opioids used for acute pain

proaches to pain management.

American Nurse Today Best of the Best

appropriate pain scale.

opioid and a short-acting formulation of the same opioid (if one

Lora McGuire is a clinical educator at Presence St.

IT S LUNCHTIME. Three of your

American Nurse Today Best of the Best

Comparing short- and rapid-acting insulin

Rapid-acting analog insulin Insulin aspart

ication errors and adverse drug

out significantly increasing hypoglycemia occurrences.

Basal-prandial insulin therapy

tively. With these regimens, dosages

Calculating basal-prandial insulin

191.8 lb (87 kg)