Barbara Pacca. See Page 20. Page 4 Guest Editorial The Nurse Education Imperative. Page 5 For Your Health

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1 Volume 34, Number 2 MARCH/APRIL 2012 FREE Continuing Nursing Education Barbara Pacca Most of us, when we hear hoof beats, think of horses. It s so easy to look at a picture and see what you most expect. As ambulatory nurses, we need to look for the unexpected a zebra instead of a horse. The Immune Deficiency Foundation (IDF) would like us to Think Zebra. Primary immune deficiency disorders (PIDD) were once believed to occur rarely in the general population. Historically they have been considered pediatric disorders because they were thought to be diagnosed most often during childhood. According to the National Institute of Child Health & Human Development (NICHD), PI diseases were once thought to be rare, mostly because only the more severe forms were recognized. Today physicians realize that PIs are not uncommon. They are sometimes relatively mild, and they can occur in teenagers and adults as often as in infants and children (NICHD, 2011). The 2007 National Patient Survey results published by the IDF conclude that diagnoses of PIDD are far more common than suggested in the literature. The exact number of persons with PI is not known. It is estimated that each year about 400 children are born in the United States with a serious PI. The number of Americans now living with a primary immunodeficiency is estimated to be between 25,000 and 50,000 (NICHD, 2011). Survey findings indicate the prevalence of PIDD in the general population to be 1 in 1,200 persons (Boyle & Buckley, 2007). Findings also confirm that primary immune deficiency disorders are no longer strictly a pediatric condition in the United States (IDF, 2007). More than half of new patients surveyed were not diagnosed with PIDD until they were age 30 or older. The average length of time from onset of symptoms to diagnosis is 12.4 years (IDF, 2007). Few of the patients participating in the survey reported a family history of PIDD; however, 9 out of 10 patients reported they experienced repeated, serious, or Page 4 Guest Editorial The Nurse Education Imperative Page 5 For Your Health Page 6 Health Care Reform Enhancing Quality and Safety Nursing Competencies in Ambulatory Care Practice Page 14 Telehealth Trials and Triumphs Attributes of an Excellent Telephone Triage Nurse Page 15 Nurses Wanted: Largest Women s Health Study Seeks 100,000 Nurses Page 16 AAACN News Page 18 AAACN Membership Speaks Out on Health Care Reform Page 19 Member Spotlight continued on page 8 Contact hour instructions, objectives, and accreditation information may be found on page 13. The Official Publication of the American Academy of Ambulatory Care Nursing See Page 20

2 Reader Services AAACN ViewPoint American Academy of Ambulatory Care Nursing East Holly Avenue, Box 56 Pitman, NJ (800) AMB-NURS Fax: (856) Web site: AAACN ViewPoint is a peer-reviewed, bimonthly newsletter that is owned and published by the American Academy of Ambulatory Care Nursing (AAACN). The newsletter is distributed to members as a direct benefit of membership. Postage paid at Deptford, NJ, and additional mailing offices. Advertising Contact Tom Greene, Advertising Representative, (856) Back Issues To order, call (800) AMB-NURS or (856) Editorial Content AAACN encourages the submission of news items and photos of interest to AAACN members. By virtue of your submission, you agree to the usage and editing of your submission for possible publication in AAACN's newsletter, Web site, and other promotional and educational materials. For manuscript submission information, copy deadlines, and tips for authors, please download the Author Guidelines and Suggestions for Potential Authors available at Please send comments, questions, and article suggestions to Managing Editor Katie Brownlow at katie@ajj.com. AAACN Publications and Products To order, visit our Web site: Reprints For permission to reprint an article, call (800) AMB-NURS or (856) Subscriptions We offer institutional subscriptions only. The cost per year is $80 U.S., $100 outside U.S. To subscribe, call (800) AMB-NURS or (856) Indexing AAACN ViewPoint is indexed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Copyright 2012 by AAACN. All rights reserved. Reproduction in whole or part, electronic or mechanical without written permission of the publisher is prohibited. The opinions expressed in AAACN ViewPoint are those of the contributors, authors and/or advertisers, and do not necessarily reflect the views of AAACN, AAACN ViewPoint, or its editorial staff. Publication Management is provided by Anthony J. Jannetti, Inc., which is accredited by the Association Management Company Institute. Choose to Be Proactive A As I write my last message to you as the president of AAACN, I am surprised and saddened at how fast the year has passed. It has been an amazing experience for me. I cannot thank everyone enough for the support they have provided. The board and I have worked to raise of our members awareness of the impact and opportunities afforded ambulatory care nurses through health care reform and the Institute of Medicine (IOM) report on the Future of Nursing. The enactment of the Affordable Care Act (March 2010), followed by release of the IOM report on the Future of Nursing Linda Brixey (October 2010), underscores nurses contribution and capacity to transform the quality of care. We have reached out to build collaborative relationships for AAACN and have been rewarded with a growing number of opportunities to have member involvement providing the ambulatory perspective in external forums. I have seen an increased willingness for our members to volunteer and am always amazed at the enthusiasm and quality of the volunteers for the various opportunities. This has been key in our ability to strategically position AAACN for wider recognition of the value of ambulatory care nurses. We are also receiving endorsements from other nursing organizations for our Position Statement on the Role of the RN in Ambulatory Care. This is very exciting! Policymakers, health care experts, and nurses are calling for nurses to optimize their contribution to improve health care quality. With 3.1 million nurses in the United States, we are the largest group of health care professionals. Corporate leadership needs more nursing involvement and to recognize the value nursing brings as members of the care team, promoting improved health care outcomes. We need to be involved in accreditation standard development and collaborative multidisciplinary work groups on legislative initiatives. We want to be full partners in providing health care and to be recognized and rewarded for our expertise. We will continue our conversations, working to develop synergies with other nursing organizations as well as other multidisciplinary care team members. There is a work group that is completing our position paper on the Role of the RN in Ambulatory Care. This is exciting for us as an organization. Better recognition of the role of the ambulatory care nurse in improving health care outcomes is not our work alone. We must be in collaborative relationships with other nursing organizations, physicians, and legislative representatives. We have convened a large and prestigious multidisciplinary team of members and non-member affiliates to work on Care Coordination Competencies. We have also invited the Academy of Medical-Surgical Nurses (AMSN) to join us in this endeavor. We are expecting this to be a very important initiative. Nursing can be instrumental in shaping the future of health care. Our professional organizations can help us influence public perception and policy decisions on important issues that directly impact quality of care, access, and scope of practice. All nurses need to be able to practice to the fullest extent of their education, training, and licensure. We need to be able to tell others how nursing improves patient outcomes and to embrace the full value and power of our profession. Much of the required change begins with us. Nursing has to participate in the transformational changes that are needed. We can lead from where we are by being aware of the quality measures that are used to evaluate patient outcomes and help management recognize the nurse s role in achieving these metrics. We must stay informed and embrace the opportunities that support the expanded role for nurses. continued on page 13 2 ViewPoint MARCH/APRIL 2012

3 Connect with Your Favorite Nurses Through Social Media Want to be Friends? Facebook is the hub of Internet social activity, and AAACN is right in the middle with a Facebook page that has over 700 fans. Nurses like you are connecting and chatting, and we re having a blast trying to make you laugh while passing on news you need. So please visit the page ( Like us, and get in the loop! While you re there, check out the new tabs for certification, job openings, ambulatory resources, and telehealth tools. You can also view photos from past conferences and share your own. Join Us for a Tweet AAACN is also active on Twitter, where we have over 1,900 followers. Are you one of them? Send us a tweet and tell us how we re doing. We d love to chat with you! Our Twitter feed broadcasts nursing news and updates on all things related to our specialty organization. Check out our profile ( follow us, and add us to your favorite lists. We ve got some handy Twitter lists for you to follow as well, so you can read streamlined tweets in focused areas such as pediatrics, veterans affairs, and patient education. Can you help us make #AAACN a trending topic? We took everything you need ed for your job search and put it in one place. Welcome to the AAACN Career Center your leading resource for an ideal position or effective recruitment. Job seekers: Find the right nursing jobs. Quicker. Get job alerts. Receive targeted s, e-newsletter, and career advice. And if you re hiring, there s something for you too. Because we re connected to other disciplines, your job posting is seen by more people every day. Connect today! 3

4 The Nurse Education Imperative Nearly 18 months after the release of the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health, it makes sense to ask: what changes are occurring? how can we make the most difference? and where can the report s recommendations take us toward improving patient care? Risa Lavizzo-Mourey One of the report s focal points, and a priority for the Robert Wood Johnson Foundation, is ensuring that nurses are educated and trained to excel as 21 st century health care delivery becomes more complex and extends beyond acute care settings. The Future of Nursing report emphasizes that if nurses are to maintain their effectiveness in providing high-quality patient care, they will need to be better prepared. Specifically, the report recommends creating a system that produces more nurses educated at the bachelor of science (BSN) level and policies that allow nurses to transition seamlessly from an associate s degree to the BSN or a higher degree. From the perspective of the IOM committee that developed the report, increasing the percentage of the workforce holding a BSN to 80% by 2020 is both an achievable goal and a necessary step to meet workforce competency and capacity requirements (Institute of Medicine [IOM], 2011). As a physician, I have seen the tremendous capabilities of nurses capabilities that are essential to meeting patient needs. But to ensure that they maximize their contributions to health and health care, nurses will need advanced skills and expertise in care management, interdisciplinary teamwork, problem solving, and more. This makes higher levels of education imperative. In addition, having a larger pool of highly educated nurses will be necessary to expand the ranks of nurse faculty, addressing the shortfall that now causes nursing schools to turn away thousands of qualified applicants each year. These advanced degree nurses are also needed to help ameliorate the worsening primary care shortage. For numerous reasons, employers will benefit from advancing levels of nurse education as well. For one, the advent of value-based payment systems will place an even greater imperative on having a highly trained health care workforce. As payers increasingly focus on hospital readmission rates, nurse-sensitive quality measures, and care coordination, nurses performance will be even more critical to the bottom line. More BSN-prepared nurses will mean a bigger cadre of nurses prepared to fully participate in interdisciplinary care teams and to take on leadership roles at the staff and executive levels in a transformed health care system. In a recent survey conducted by AONE (Caramanica & Thompson, 2012), 51% of nurse leaders said their organizations preferentially hire BSN nurses, although just 32% pay BSN nurses more at the time of hire. Lack of access to BSN nurses and lack of support from organizational leaders were cited as the top barriers to such policies. Ninety-three percent of survey respondents noted that their institutions offer tuition benefits to support associate s degree-to-bsn advancement. Some of the leading nurse employers favor advanced degree nurses. The well-respected Johns Hopkins Hospital has a stated preference for hiring BSN nurses and requires nurses to obtain at least a BSN before going beyond a certain point on the career ladder. The for-profit Tenet Health Care Corporation has adopted similar policies, and the Veteran s Health Administration also links education to career advancement (Pittman, Horton, Keeton, & Herrera, 2011). These policies can yield positive benefits, but monetizing the return on investment is challenging. We know that turnover rates are sensitive to human resources policies, including tuition reimbursement and career-ladder programs that provide growth opportunities (Pittman et al., 2011). There is evidence that organizations that earn the Magnet Recognition Program credential for nursing excellence have lower turnover rates among nurses and thus have improved clinical outcomes (Drenkard, 2010). In Magnetdesignated organizations, chief nursing officers and 75% of nurse managers are required to have a BSN degree or higher (Frellick, 2011). An important consideration for employers is that education progression policies may yield savings that result from lower nurse turnover and vacancies, estimated to cost from $22,000 to $64,000 per position (Strachota, Normandin, O Brien, Clary, & Krukow, 2003). We cannot wait to take action; failing to grow a better educated nursing workforce risks disastrous results. This is particularly important in light of the aging nursing workforce as well as the coming expansion of health insurance coverage in Although a recent study shows faster growth in the supply of nurses than anticipated, its authors caution that more progress is needed to meet our aging population s need for highly skilled nurses (Auerbach, Buerhaus, & Staiger, 2011). Around the country, educational institutions are finding creative ways of encouraging and facilitating progression to BSN and higher-level degrees. For example, the Oregon Consortium for Nursing Education has created a shared curriculum across 8 community colleges and the Oregon Health & Science University School of Nursing, which enables students to complete BSN coursework without leaving their home community. Graduates are trained in clinical judgment, patient-centered care, systems thinking, leadership, and evidence-based practice. In New Mexico, leaders will discard 24 separate curricula in favor Note: Reprinted with permission from Elsevier. Lavizzo- Mourey, R. (2012). The nurse education imperative. Nursing Outlook. doi: /j.outlook ViewPoint MARCH/APRIL 2012

5 of a uniform nursing curriculum and a shared faculty pool. Florida is developing RN-to-BSN educational models, including community college transition to state college programs and community college transition to state university regional partnerships. Colorado is developing such partnerships as well. These are shining examples of the evolution that needs to occur nationwide. To meet our nation s health care needs, we must strengthen the nursing profession at all levels, from the front lines to the executive ranks. That is precisely why we partnered with the IOM to develop the report and why we are actively engaged in facilitating its implementation through the Future of Nursing: Campaign for Action. Tackling the barriers to educational progression requires a multifaceted approach. Far from being solvable with a single action or within a single arena, realizing fullscale change will take the commitment of many in health care, education, business, and other sectors. A key component of our effort is working with national stakeholders through the Center to Champion Nursing in America, an initiative of the AARP, the AARP Foundation, and the Robert Wood Johnson Foundation. Because nursing is so critical to improving health care, it is a priority for our foundation and one to which we have devoted more than $300 million over the last 10 years. At the Robert Wood Johnson Foundation, the IOM report is our blueprint for transforming the nursing profession to help ensure that all patients receive the care they need and deserve. We will continue to address its recommendations and encourage many others to do the same to fully realize the Campaign for Action s vision: a nation where all have access to high-quality, patient-centered care in a health care system in which nurses contribute as essential partners in achieving success. References Auerbach, D.I., Buerhaus, P.I., & Staiger, D.O. (2011). Registered nurse supply grows faster than projected amid surge in new entrants ages Health Affairs, 30(12), Caramanica, L., & Thompson, P.A. (2012, January). AONE survey: Gauging hospitals use of preferential hiring policies for BSNprepared nurses. Voice of Nursing Leadership, 1, Drenkard, K. (2010). The business case for Magnet. Journal of Nursing Administration, 40(6), Frellick, M. (2011). A path to nursing excellence. Trustee, 64, 201. Retrieved from jsp/articledisplay.jsp?dcrpath=trusteemag/article/data/03m AR2011/1103TRU_FEA_PathToNursingExcellence&domain¼T RUSTEEMAG Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing heath. Atlanta, GA: The National Academies Press. Pittman P., Horton, K., Keeton, A., & Herrera, C. (2011, November). Investing in nurse education: Is there a business case for employers? Manuscript in preparation. Strachota, E., Normandin, P., O Brien, N., Clary, M., & Krukow, B. (2003). Reasons registered nurses leave or change employment status. Journal of Nursing Administration, 33(2), Risa Lavizzo-Mourey, MD, MBA, is President and CEO, Robert Wood Johnson Foundation, Princeton, NJ. March is colorectal cancer awareness month! For more information to share with your patients on the signs and symptoms and diagnostic tests available, check out this information at the National Cancer Institute: colorectal/patient/page3 Sleep disorders can affect health care staff as well as patients. Check out this list of seven tips for better sleep: Poison prevention is key in the spring! Call and ask a Poison Control educator for stickers, magnets, brochures, or other poison prevention materials. If you need information in a variety of foreign languages, check out this site, The American Association of Poison Control Centers: Prevention/OrderPoisonPreventionMaterials.aspx Autism, pervasive developmental disorders, and Asperger s syndrome are becoming more prevalent. To direct your patients to reliable information, have them access information from Autism Speaks: speaks.org/family-services/resource-library Carol Ann Attwood, MLS, AHIP, MPH, RN,C, is a Medical Librarian, Patient Health and Education Library, Mayo Clinic Arizona, Scottsdale, AZ, and a ViewPoint Editorial Board member. She can be contacted at attwood.carol@mayo.edu Cleveland LNG Raises Funds To Help Children The Cleveland local networking group (LNG) of the Academy of Ambulatory Care Nursing raised donations for the Providence House in Cleveland, OH. The Providence House is one of the nation s oldest operating crisis nurseries, offering emergency shelter and care to children who are actively at risk for abuse and neglect due to family crisis. The Cleveland Academy of Ambulatory Care Nursing (CAACN) raised $250 among its members, matched that with local networking group funds, and was able to present $500 to help with holiday needs for the children. The Cleveland LNG has 25 formal members with an additional interested parties on our mailing list. We meet monthly at a local restaurant, have speakers who provide continuing nursing education (CNE) offerings, and hold discussion and networking after. We meet from September until June, with the June meeting being a social/recruiting event with appetizers provided. We have representatives from 4 area hospitals/ambulatory clinics and have found friends and colleagues through our common interests. Submitted by Kitty Ribar, BSN, RN 5

6 View health care reform resources online at: Enhancing Quality and Safety Nursing Competencies In Ambulatory Care Practice In the last issue of ViewPoint, the new Centers for Medicare and Medicaid Services (CMS) Never Events were presented and discussed, as well as how CMS considers these to be events that should never occur in ambulatory care settings (Haas, 2012). This ruling can have major reimbursement consequences, but also requires that nurses and other providers in ambulatory care settings become much more aware of quality and safety issues and ways to prevent never events through evidence-based practice (EBP) and use of the electronic health record (EHR). The Institute of Medicine (IOM) has provided multiple reports on the status of health care in the U.S. starting with To Error is Human in 1999, where flawed systems were identified as a major cause of error. In 2001, the IOM report Crossing the Quality Chasm delineated issues with quality and safety and recommended 6 aims for U.S. health care (see Figure 1). There have been follow-up reports by the IOM (2003) where the need for practitioners to gain expertise in the areas of quality and safety are addressed. The Robert Wood Johnson Foundation funded work by Cronenwett and colleagues (Cronenwett et al., 2007; Cronenwett, Sherwood, & Gelmon, 2009a; Cronenwett, Sherwood, Pohl, et al., 2009b) called Quality and Safety in Education in Nursing (QSEN). The IOM s six aims are the foundation for QSEN s six competencies. Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduate quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes (KSAs) to be developed in nursing pre-licensure and graduate programs for each competency (QSEN 2012a, 2012b): Patient Centered Care Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient s preferences, values, and needs. Quality Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Teamwork and Collaboration Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality care. Safety Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Safe: avoiding injuries to patients from the care that is intended to help them. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Source: IOM, Figure 1. IOM (2001) Six Aims for Improvement Evidence-Based Practice Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making. These competencies, as defined above, provide the KSAs that make up each competency. The QSEN competencies are now part of accreditation standards for prelicensure and graduate education and are content tested in licensing and certification exams. Nursing students who are now graduating will have had exposure to these competencies in theory, simulation, and clinical classes. Of concern is the fact that nurses currently practicing may not be as familiar with the QSEN competencies. When and if new graduate nurses move into ambulatory care, they will expect to see EBP, Quality Councils, and EHR where nurses document care processes and outcomes. If this is not the norm for nursing in an ambulatory setting, retention of nurses could be an issue, as well as poor patient and organization outcomes. Concern regarding competency with quality and safety extends beyond nursing. The Lucian Leape Institute issued a report in 2010 that was highly critical of the lack of quality and safety content and experience in medical 6 ViewPoint MARCH/APRIL 2012

7 student and residency programs. Prevention and management of potential never events in ambulatory settings requires competencies in all six of the areas specified in QSEN. However, this column will focus only on the EBP and Informatics QSEN competencies because they are a major focus of the health reform law. It is expected that providers, nurses, physicians, and other health care professionals will use best evidence-based practices in the provision of care and that they will track evidence-based processes and outcomes achieved. Tracking is where informatics comes into play. The Accountable Care law provides funding for equipment to support the EHR, especially in primary care practice. It is the expectation that the EHR will enhance communication within the health care team and across settings and decrease errors and costs due to duplication of testing, lost test results, etc. The EHR is also key to tracking evidence-based processes of care and outcomes. In addition to falls and pressure ulcers discussed as potential never events in ambulatory care in our last ViewPoint issue, surgical or invasive procedure events and product or devise events in ambulatory care are also of concern. The Joint Commission requires use of the Universal Protocol in all accredited hospitals, ambulatory care, and office-based surgical practices to prevent such events and there is evidence that can be employed in EBP protocols to prevent adverse surgical or device events. So where do ambulatory nurse leaders start? The QSEN Web site ( is a great resource. It is designed to assist in both nursing student and staff education, as well as education of the educator. You can search for teaching strategies by indicating which QSEN competency you want to work on, your learning setting, learner level, and strategy type (such as simulation). There are also yearly QSEN conferences where those who are using QSEN share strategies and methods. For the EBP competency, there are free interdisciplinary Web-based modules ( These interactive modules were funded by a grant from the National Institutes of Health. Another great resource funded by the Agency for Healthcare Research and Quality is a text edited by Hughes (2008) titled Patient Safety and Quality: An Evidence-Based Handbook for Nurses. This 3-volume text is FREE to nurses on CD-ROM from Knowing that there are resources available to upgrade and update ambulatory care nurses understanding of EBP and use the EHR, the first step for ambulatory care nurse leaders should be developing a strategic plan for prevention of never events in ambulatory care. Such a plan starts with developing an understanding among leadership and nurses and an appreciation of the issue of never events, methods to identify potential for them in ambulatory care settings, methods to develop or enhance understanding and comfort with development of EBP protocols suited to the ambulatory care setting, and knowledge and skills with use of documentation formats in EHR to track EBP processes and outcomes. Such a project may seem overwhelming, but leaders need to look at one potential never event at a time. For example, look at historical data on falls or operating room errors so you can see where you should start. Begin with work on the event that has the highest incidence and the one that will have the greatest costs, both in poor patient outcomes as well as financial, should it occur and thus the greatest return on investments that will be made in EBP and the EHR. Much of the cost is related to education time for staff as well as development time needed for work on EBP protocols and EHR documentation formats. While there are financial incentives to EBP and the use of EHR, there is a greater incentive that ambulatory nurses will respond to providing higher quality and safer care to their patients. References Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Warren, J. (2007). Improving quality and safety education. Nursing Outlook, 55(7), Cronenwett, L., Sherwood, G., & Gelmon, S., (2009). Improving quality and safety education: The QSEN Learning Collaborative. Nursing Outlook, 57(6), Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D., Warren, J. (2009). Quality and safety education for advanced nursing practice. Nursing Outlook, 57(6), Haas, S.A. (2012). Prevention and early detection of never events within ambulatory settings to enhance quality and safety and prevent financial losses. ViewPoint, 34(1), 6-8. Hughes, R. (Ed.) (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from qual/nurseshdbk/ Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. Retrieved from Human-Building-A-Safer-Health-System.aspx Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21 st century. Washington, DC: National Academies Press. Retrieved from Report%20Files/2001/Crossing-the-QualityChasm/Quality %20Chasm%202001%20%20report%20brief.pdf Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press, Quality and Safety in Nursing Education. Retrieved from Education-A-Bridge-to-Quality.aspx Lucian Leape Institute. (2010). Unmet needs: Teaching physicians to provide safe patient care. Retrieved from npsfstore.com/categories/publications Quality and Safety Education for Nurses (QSEN). (2012a). Competency KSAs (graduate). Retrieved from ksas_graduate.php Quality and Safety Education for Nurses (QSEN). (2012b). Competency KSAs (pre-licensure). Retrieved from ksas_prelicensure.php Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be contacted at shaas@luc.edu 7

8 Think Zebra continued from page 1 unusual infections prior to diagnosis (IDF, 2007). The goal of this article is to raise awareness regarding PIDD in the ambulatory nursing community. Primary immune deficiency disorders are a group of conditions in which the patient has an intrinsic immune system defect in his or her immune system. There are currently more than 150 different diagnoses recognized by the World Health Organization as PIDD (Boyle & Buckley, 2007). Making a PIDD diagnosis is challenging because there aren t any clearly recognizable or unique symptoms. The patient frequently presents with symptoms of infections, which can be persistent and/or chronic. It is not unusual in our practice to hear from a new patient and family with a child who has been sick for a long period of time sometimes years. Often several different physicians and specialists saw the child before there was a correct diagnosis and appropriate referral for treatment. If the patient, family, or health care provider does not look beyond the individual episode requiring treatment, the underlying cause may go undetected. The Jeffrey Modell Foundation (2012) created the 10 Warning Signs of PIDD to help raise awareness of these disorders. The list for children is as follows (variations for adults are noted): 1. Four or more new ear infections within one year (two or more for adults) 2. Two or more serious sinus infections within one year (in absence of allergy for adults) 3. Two or more months on antibiotics with little effect 4. Two or more pneumonias within one year (one or more for adults) 5. Failure of an infant to gain weight or grow normally 6. Recurrent deep abscesses of the skin or internal organs 7. Recurrent need for intravenous antibiotics to clear infections 8. Persistent thrush or fungal infection 9. Two or more deep-seated infections including septicemia (not noted in adult criteria) 10. A family history of PIDD Also included in diagnosing an adult is an infection with normally harmless tuberculosis-like bacteria and chronic diarrhea with weight loss (Jeffrey Modell Foundation, 2012). This information is available on the Foundation Web site ( Evaluation may include a detailed medical history, thorough physical examination, blood tests, and vaccines to test the immune response. A routine CBC with differential that shows a low lymphocyte count (especially if it persists in follow-up testing) may warrant closer examination by an immunologist. Other lab tests frequently used in diagnosis are IgG, IgA, IgM, and IgE levels, delayed-type hypersensitivity skin tests, mitogen and antigen studies that look at T cell response to stimuli, and CD19 and CD20 for B cell lymphocytes present in the circulation. Frequently, patients are given vaccines (not live virus) followed by titers to check for the body s response to those vaccines. Patients with undiagnosed and untreated PIDD are unable to produce antibodies sufficient to fight infection. Administration of live viruses to a patient with a compromised immune system can result in serious illness or death. In addition, siblings and other household contacts should not receive live virus vaccines due to the potential for disease transmission (Winkelstein, 1996). PIDD vary in prevalence from relatively common to very rare (Burton, Murphy, & Riley, 2009, p. 6). Examples of some of the better-known disorders are noted in Table 1 (see page 10). This table presents only basic information regarding PIDD. The wide range of symptoms and variability among disorders makes it impossible to include details for any one specific disorder in this format. It is worth special note that severe combined immune deficiency (SCID) usually manifests in infancy, and without early diagnosis, has poor outcomes for the patient. SCID is sometimes known as bubble boy disease. When diagnosed at birth, these patients receive a bone marrow transplant within the first ten days of life. In January of 2010, the Advisory Committee on Heritable Disorders in Newborns and Children voted to add screening for SCID to the core panel of universal screening of newborns in the United States (Gill, 2010). To date, it is the only form of PIDD for which routine screening has been established. For many patients with PIDD, treatment includes IgG replacement therapy given intravenously or subcutaneously. Intravenous infusions of immune globulin (IVIG) are usually given every 3-4 weeks and can be given in an infusion center or at home through a home care agency. Home IVIG infusions should be provided through a home care agency with a nurse present during infusion. Subcutaneous infusions are usually given weekly at home and administered by the patient or a family member following initial training by a health care provider (Skoda-Smith, Torgerson, & Ochs, 2010). Having options for the method of administration of IgG gives the patient some control over his or her treatment options and lifestyle. Stem cell transplants have been used for some patients with PIDD with positive outcomes. The primary immunodeficiency diseases for which HSCT (hemapoetic stem cell transplant) is most commonly performed include those diseases that are characterized by deficient T-lymphocytes or combined deficiencies of T-lymphocytes and B-lymphocytes. HSCT is most often used to treat SCID. HSCT has also been used in some patients to treat other primary immunodeficiency diseases such as the Wiskott-Aldrich syndrome, hyper-igm syndromes, and chronic granulomatous disease (IDF, 2007). Clinical trials with gene therapy are also being done with these same patient populations with mixed results. Stem cell transplants and gene therapy show tremendous potential for the treatment of T-lymphocyte disorders and combined T-lymphocyte and B-lymphocyte disorders, but more research is needed. Throughout adult life, patients remain stable in both the management of their condition and the condition itself by adhering to the chronic care management (CCM) model (Burton et al., 2009, p. 8). This model includes disease prevention, evidence-based interventions, along with 8 ViewPoint MARCH/APRIL 2012

9 several other tenets of traditional care supported by research and education. Burton and colleagues (2009) further discussed the new patient-centered PIDD CCM based on the Expert Patient Program started in the United Kingdom in The five core proficiencies identified as necessary to becoming an expert patient are as follows: Problem-solving Decision-making Resource maximization Developing effective partnerships with health care providers Appropriate interventions The focus of this new CCM for PIDD is enabling complete patient self-management from the patient s perspective (Burton et al., 2009, p. 8). Assisting patients to be experts in their own care would help to establish them as effective partners with their health care providers. This type of health care consumer/provider relationship is consistent with the National Prevention Strategy (U.S. Department of Health and Human Services, 2012) and would support the goals of Health Care Reform. For patients with PIDD, being educated about their disorder and having the ability to advocate for their health care needs can make a significant difference in their ability to reach their optimal health potential. Effective management of chronic disease is the key to both reducing health care expenses and improving patients quality of life (Burton et al., 2009, p. 5). Resources for health care providers, patients, and families are available through the Internet or in print. The Immune Deficiency Foundation ( and the Jeffrey Modell Foundation ( are both reliable sources of information. The IDF mission includes PIDD research and patient advocacy among its many offerings. Their Think Zebra campaign was established to promote awareness of PIDD. They have also published a handbook for patients and families as well as a nurses guide to IVIG. The handbook contains basic information as well as a section dedicated to each of the most common diagnoses. The IDF also sponsors an online continuing education course for nurses that includes detailed information about PIDD. The course is free, provides 5 contact hour credits, and can be found on their Web site. IG Living magazine ( is a useful resource for patients and families receiving immune globulin therapy. It has been in publication for several years and is sponsored by several manufacturers of IVIG products. Subscriptions are free. All of us, as ambulatory care nurses, are in a position to listen to our patients stories, hear what they are saying, and collaborate with them to look at the big picture. Early diagnosis and treatment leads to the best possible outcomes for PIDD patients. So remember: The next time you hear hoof beats, Think Zebra! References Boyle, J.M., & Buckley, R.H. (2007). Population prevalence of primary immunodeficiency diseases in the United States. Journal of Clinical Immunology, 27(5), Burton, J., Murphy, E., & Riley, P. (2010). Primary immunodeficiency disease: A model for case management of chronic disease. Professional Case Management, 15(1), Gill, J.D. (2010). Newborn screening for SCID The time is now. IDF Advocate, 63, 1-5. Retrieved from publication_s/newsletter/idf_newsletter63_spring10.pdf Immune Deficiency Foundation (IDF). (2007). IDF national survey of patients. Retrieved from Jeffrey Modell Foundation. (2012). National primary immunodeficiency resource center. Retrieved from National Institute of Child Health & Human Development (NICHD). (2011). Primary immunodeficiency. Retrieved from cfm Primary Immunodeficiency Resource Center. (2009). 10 warning signs of primary immunodeficiency. Retrieved from content=warningsigns Skoda-Smith, S., Torgerson, T.R., & Ochs, H.D. (2010). Subcutaneous immunoglobulin replacement therapy in the treatment of patients with primary immunodeficiency. Therapeutics and Clinical Risk Management, 6, U.S. Department of Health and Human Services. (2012). National prevention strategy. Retrieved from Winkelstein, M.L. (1996). Primary immune deficiency diseases: A guide for nurses. Towson, MD: Immune Deficiency Foundation. Suggested Reading Burton, J., Murphy, E., & Riley, P. (2010). Primary immunodeficiency disease: A model for case management of chronic disease. Professional Case Management, 15(1), Barbara Pacca, RN, BSN, CPN, HTPA, is a Clinical Nurse IV, Children s Hospital of Philadelphia, Philadelphia, PA. AAACN Marketing Opportunities Advertise with AAACN and reach more than 2,000 nurse managers and supervisors, nurse administrators and directors, staff nurses, educators, consultants, NPs, and researchers the ideal audience for your sales and marketing message! Marketing opportunities include: Exhibiting at the AAACN Annual Conference Corporate sponsorships Premium advertising ViewPoint, the AAACN official newsletter AAACN Web site AAACN monthly Enewsletter Online Library Conference program book For more information, contact Marketing Director Tom Greene at greenet@ajj.com or

10 Table 1. Examples of Primary Immune Deficiency Disorders PIDD Characteristics Inheritance Common Variable Immune Deficiency (CVID) X-linked Agammaglobulinemia (XLA) B-lymphocyte disorder Most common form of PIDD Low serum levels of immune globulins Symptoms vary in severity Recurrent infections of ears, sinuses, nose bronchi, and lungs B-lymphocyte disorder Unable to produce antibodies Have small tonsils and lymph nodes on physical exam Prone to infections in sinuses, middle ear, eyes, and lungs Unclear genetic nature Affects males and females X-linked recessive Disease presents in males; females can be carriers Age at Onset of Symptoms or Diagnoses Variable 20% are less than 16 years of age Some are diagnosed in the third or fourth decade of life Usually within the first few years of life Treatment Options Prompt treatment of infections Antibiotic therapy Immune globulin replacement Prompt treatment of infections Antibiotic therapy Immune globulin replacement Treatment Goals or Life Expectancy Keep patient infection free Prevent development of chronic lung disease Extra attention needed in preventing/ treating infections With treatment, a full and active lifestyle is possible Selective IgA Deficiency B-lymphocyte disorder One of the most common PIDD, occurring in 1 in 500 people Absence of IgA in serum and secretions Severity of symptoms varies from relatively healthy to significant illness; about 50% have increased susceptibility to infection 25-33% have autoimmune disease 10-15% have allergies/asthma Considered to have increased risk of anaphylaxis with blood products including immune globulin None identified Affects males and females Varies with severity of symptoms Frequent assessment and reevaluation by health care provider to maintain optimal health Strong communication between patient/family and health care provider to initiate treatment as soon as disease process is identified Long-term outcomes are unpredictable; prognosis depends on prognosis of associated diseases Severe Combined Immune Deficiency (SCID) Combined B-lymphocyte and T-lymphocyte disorder Extreme susceptibility to infection Sometimes called bubble boy disease Several known genetic causes Most common is X-linked recessive (45%) affecting males Remainder are autosomal recessive affecting males and females Can also be a new mutation in the affected infant Can be diagnosed in utero Symptomatic at or shortly after birth Bone marrow transplant usually shortly after birth Gene therapy Supplemental treatment can include immune globulin replacement therapy, frequent painful procedures, and hospitalizations If blood or platelet transfusion is necessary, only irradiated, CMV negative, leukocytedepleted products should be used Most serious form of PIDD Affected infants need to be isolated from others outside the home Without treatment, risk of infection is severe and can be fatal 10 ViewPoint MARCH/APRIL 2012

11 Table 1. (continued) Examples of Primary Immune Deficiency Disorders PIDD Characteristics Inheritance Chronic Granulomatous Disease (CGD) Phagocytic disorder Susceptible to certain bacterial and fungal infections Characteristic granuloma formation at site of infection or inflammation Usually X-linked affecting males Can also be autosomal recessive affecting males and females Approximately 15% of CGD patient are female Age at Onset of Symptoms or Diagnoses First few months to first few years of life Treatment Options Early diagnosis of infection Aggressive antibiotic therapy Gamma interferon Treatment Goals or Life Expectancy May need recurrent hospitalizations and IV antibiotics to treat infection Can lead full, productive lives into adulthood Wiskott-Aldrich Syndrome (WAS) Combined B-lymphocyte and T-lymphocyte disorder Low platelet count with increased tendency for bleeding Recurrent bacterial, viral, or fungal infections Eczema Increased incidence of malignancy Increased incidence of autoimmune disease X-linked affecting males Shortly after birth or within the first year of life Bone marrow transplant Cord blood stem cell transplant Gene therapy Supplemental treatment can include appropriate treatment of eczema, immune globulin replacement, antibiotic therapy, and platelet transfusion; when absolutely necessary, splenectomy can be done for low platelet counts 30 years ago, life expectancy was 2-3 years of age Currently the oldest bone marrow transplant recipients are now years old and leading full, productive lives Hyper IgE Syndrome (HIES) Affects the immune system, bones, connective tissue, and teeth Characteristic skin boils Also common to present with rashes, upper respiratory infections, recurrent pneumonia, sinusitis, ear infections, skeletal abnormalities, characteristic facial appearance, bone fractures, or retention of primary teeth Very rare with approximately 200 published cases Can be autosomal dominant or autosomal recessive affecting both genders Usually within first few months of life Appropriate skin care Early treatment of infection Antibiotic therapy (topical and oral) Conflicting evidence to support use of interferon, immune globulin replacement therapy, G-CSF Require constant vigilance regarding infection and chronic lung disease Can lead full, productive lives into adulthood Hyper IgM Syndrome Immune system defects affect the interaction between B- lymphocytes and T- lymphocytes Increased susceptibility to infection Approximately 50% develop neutropenia Frequently have enlarged tonsils, big spleen and liver, or enlarged lymph nodes Can be X-linked recessive affecting males or autosomal recessive affecting both genders First or second year of life Immune globulin replacement therapy Antibiotic therapy G-CSF for neutropenia More recently, bone marrow transplant or cord blood stem cell transplant have been used Can lead full, productive lives 11

12 Table 1. (continued) Examples of Primary Immune Deficiency Disorders DiGeorge Syndrome PIDD Characteristics Inheritance T-lymphocyte disorder Frequently associated with 22q11.2 deletion syndrome Characteristic facial features Parathyroid abnormalities sometimes leading to decreased serum calcium levels and/or seizures Cardiac defects Thymus gland abnormalities Caused by abnormal migration and development of certain cells and tissues during growth and differentiation of the fetus Age at Onset of Symptoms or Diagnoses At birth or soon after Treatment Options Correction of defects in organs and tissues; can require painful procedures, surgeries, and possibly recurrent hospitalization Treatment of low calcium levels Treatment of any allergies Prophylactic antibiotics Treatment Goals or Life Expectancy Dependent on the degree to which the patient is affected IgG Subclasses Low levels of 1 or 2 IgG subclasses Susceptible to certain infections but not others Frequently present with recurrent infections of the ear, sinuses, bronchi, and lungs Frequently unable to produce adequate antibodies to unconjugated polysaccharide vaccines (pneumococcus or haemophilus) More common in children than adults No clear pattern of inheritance Not specified Immune globulin replacement therapy Antibiotic therapy Periodic reevaluation of immunoglobulin and IgG subclass levels Many children outgrow their deficiency as they get older Prognosis is generally good Ataxia Telangectasia Combined B-lymphocyte and T-lymphocyte disorder Present with neurological abnormalities, unsteady gait, or dilated blood vessels of the eyes and skin Increased susceptibility to infection Predisposition to certain cancers Autosomal recessive affecting males and females Initial onset of symptoms is often at months Diagnosis is frequently not made until age 5-6 years, when symptoms worsen Treatment is primarily supportive Immune globulin replacement Antibiotic therapy Physical and/or occupational therapy Learning support in school Disease course is variable and progressive Recurrent lung infections are common Complement Deficiency C1-4: C2 is most common, occurring in 1 in 10,000 in the general population Prone to autoimmune disorders C5-9 deficiencies cause increased susceptibility to Neisseria family of bacteria C1 inhibitor deficiency Often have hereditary angioedema (HAE), presenting with swelling of the tissue under the skin, usually affecting hands, feet, bowel, mouth, and airway Most are autosomal recessive C1Inhibitor is autosomal dominant Not specified Early and aggressive treatment of symptoms Prognosis is generally good with patients leading full, productive lives Source: Compiled from information obtained from the Patient & Family Handbook for Primary Immunodeficiency Diseases, Fourth Edition. Copyright 2007 by Immune Deficiency Foundation ( 12 ViewPoint MARCH/APRIL 2012

13 Instructions for Continuing Nursing Education Contact Hours Think Zebra: Promoting Awareness of PIDD Deadline for Submission: April 30, 2014 To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation online in the AAACN Online Library. ViewPoint contact hours are free to AAACN members. Visit and log in using your AAACN address and password. (Use the same log in and password for your AAACN Web site account and Online Library account.) Click ViewPoint Articles in the left hand navigation bar. Read the ViewPoint article of your choosing, complete the online evaluation for that article, and print your CNE certificate. Certificates are always available under CNE Transcript (left side of page). 2. Upon completion of the evaluation, a certificate for 1.0 contact hour(s) may be printed. Fees AAACN members: FREE Regular price: $20 Objectives The purpose of this continuing nursing education article is to increase the awareness of primary immune deficiency disorders (PIDD) in nurses and other health care professionals. After studying the information presented in this article, you will be able to: 1. Define primary immune deficiency disorders (PIDD). 2. Discuss the history of PIDD and how and when they are typically diagnosed. 3. Identify the 10 warning signs for PIDD. 4. Explain treatment options for PIDD. The authors have not disclosed any affiliation or financial interest in relation to this educational activity. This educational activity has been co-provided by AAACN and Anthony J. Jannetti, Inc. Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses' Credentialing Center's Commission on Accreditation (ANCC-COA). AAACN is an approved provider of continuing nursing education by the California Board of Registered Nursing, provider number CEP5366. California licensees must retain this document for four years. This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE- BC, Education Director. Interested in Writing for? Consider sharing your ambulatory care or telehealth nursing expertise by writing an article for ViewPoint! Download author guidelines, copy deadlines, and tips for authors at See page 17 for a list of suggested topics. President s Message continued from page 2 As I look at our volunteerism, I reflect that each of us is responsible for our own actions. We can choose to be reactive, allowing others to define us, or we can proactively take the lead, being involved during planning and development of initiatives that require nursing expertise. The National Council of State Boards of Nursing (NCSBN) has been promoting the Nurse Licensure Compact to improve access to practice across state lines. Many states have developed state action coalitions that lobby for pro-nursing legislative initiatives. By supporting their activity, we promote nursing, voice our concerns, and express the need for a more consistent and better defined scope of practice for us all. Laws governing our practice are made by legislators. If we do not let them hear from us, they will hear from others such as physician groups and hospital administrators. We must be present and participate to be heard. We need to build and share our professional knowledge. The IOM recommends residency programs. As they become a reality, ambulatory care needs to contribute to the planning and development. Residency programs target new graduates. We should also look at other opportunities such as transitional programming, which may allow us to retain nurses who would otherwise leave the profession. Programs that support transitioning into another field of nursing through advanced education and competence development are equally important as the programs for new graduates. We have included a reprint from Nursing Outlook in this issue of ViewPoint (see page 4) related to the IOM s nurse education imperative by Risa Lavizzo-Mourey, MD. Her article stresses the importance of our participation in meeting the requirement of our expanding role by ensuring that nurses are educated and trained in the advanced skills, expertise, and care coordination needed to excel. Your membership in a professional nursing organization such as AAACN is an important way to leverage the collective energy and resources of our larger body of nurses. Nursing associations provide educational programs and tools for practice, support positive policy changes, encourage research, and advocate on issues important to the profession. Many times a professional membership provides opportunities to participate in workforce planning surveys and other data collection opportunities. If we don t use our voice, we will not be heard and will be left behind. Thank you again for the opportunity to serve as your president. I truly appreciate all the work of our volunteers who have helped make this year a great success. I hope to see you at our May 2-5 conference in Lake Buena Vista, Florida! Linda Brixey, RN, is Program Manager, Clinical Education, Kelsey- Seybold Clinic, Houston, TX. She can be contacted at 13

14 Attributes of an Excellent Telephone Triage Nurse Over the past year, I have been presenting telephone triage seminars for Telephone Triage Consulting, Inc. During and after presentations, I am often asked what attributes a nurse should possess to be effective in triaging a patient over the phone. Ideally, every nurse in every area of nursing should possess all of these attributes. However, it is important for telephone triage nurses to possess all of them because of the unique relationship they have with the patient. Nurse and patient have a dialogue that lasts only several minutes. During this brief encounter, the telephone triage nurse assesses the patient through the patient s self-assessment. The plan of care is based on the nurse s inquiry and discovery. Telephone triage nurses practice sophisticated nursing and they have to be masters in the profession to do it effectively. If they possess the ten following characteristics, they will be highly successful. Ironically, every characteristic begins with the letter c. C aring A caring attitude is the most essential characteristic that every nurse should possess. When you care for patients, you watch over them and take responsibility for their well-being. As a telephone triage nurse, you provide advice that results in comfort and healing. You cannot provide care through your touch, but your patients will know you care through your voice. C ompassionate Compassion is concern for someone else s suffering and a desire to alleviate his or her suffering. Compassion resides in the heart of a nurse. Practicing nursing without compassion is like providing first aid without any feeling. When caring for a patient over the phone, the nurse s focus and voice will relay the compassion the nurse feels in her or his heart. Critical Thinking According to Yıldırım and Özkahraman (2011), critical thinking is the process of searching, obtaining, evaluating, analyzing, synthesizing, and conceptualizing information as a guide for developing one s thinking with selfawareness, and the ability to use this information by adding creativity and taking risks. The ability to critically think is essential as nurses collect large volumes of patient-reported symptom information and determine the appropriate level of care. Common Sense According to Cambridge Dictionary, common sense is the basic level of practical knowledge and judgment that is needed to live in a reasonable and safe way. In conversations with patients, it is essential that we execute our common sense to help them also manage their situation and symptoms in a reasonable and safe way. A scenario that illustrates this is as follows: You triage a patient at 3:00 a.m. According to his symptoms, you advise that he is seen within four hours. The only area of care available within the four-hour span is the emergency room. If the patient waits until 8:00 a.m., he would be able to be seen in the clinic with his primary care provider. Common sense would allow you to recommend he be seen by his own caregiver. C ompetence Being competent is having the knowledge, skill, and experience to safely care for patients over the phone. How is this accomplished? It is important to hire nurses who have a minimum of five years experience and then provide them with an organized and individualized orientation and provide educational opportunities on a consistent basis. You can ensure your own competence by attending conferences, reading nursing journals, and achieving nursing specialty certification. C onfidence As a telephone triage nurse, you need to be confident with your decision-making ability. Even when patients are vague, your ability to interview and clarify their situation will lead to clear advice. If you are competent and you possess the ability to think critically, you can efficiently manage a patient s questions and symptoms. You will confidently recommend the appropriate level of care. The patient will sense your confidence and they will feel calmer and directed. They too will feel confident no matter what level of care you recommend. C ourteous Although courtesy is a basic customer service skill, it can be forgotten when call volume is high and patients are stressed. Yet being respectful and kind when you are talking to patients over the phone is essential to build a relationship of trust with your callers. Excellent C ommunication Your patients cannot see you. You have to excel with your ability to communicate. You need to get the information you need to formulate a plan that is realistic, safe, and manageable. Communication involves a two-way flow of information. It is not just about talking; it is also about listening to your patients. You need to ask open-ended questions, utilize reflective listening, relay empathy, and keep the conversation focused. Utilizing effective communication strategies will lead to a trusting rapport between you and your caller. C urious Being curious is not often mentioned as a valuable attribute for a telephone triage nurse. However, it is curiosity that will lead you to act on your hunch. It is curiosity that will compel you to ask about background noises. And it is curiosity that will remind you to ask, Is there anything else that is going on? And it may be that curious question 14 ViewPoint MARCH/APRIL 2012

15 that will lead to the real reason for the patient s call to you. Curiosity may have killed the cat, but curiosity keeps the telephone triage nurse vital. C autious In the area of telephone triage nursing, you will often hear that being cautious is a good thing. Without our ability to use all of our senses in our assessment, we have to be more cautious. If we cannot build a picture of the patient through the triage process, we have to recommend that the patient be seen. We cannot take a risk when it involves a patient s well-being and life. We cannot afford to make a mistake. Being cautious is a good thing. C urrent Keeping current on the latest research and best practices will keep your nursing practice at a high level. It is also important to keep current with news, health trends, and fads. Our callers are often getting much of their information from television and the Internet. We have to know when there are behaviors that our callers are engaging in holistic and conventional. One example of this is when there is an outbreak of food poisoning from an identified offender. You may receive calls about potential symptoms even if the incident has occurred in another area of the country. Another example is when callers see a commercial about new medication and its side effects; they may want you to address these. Hopefully you can identify most of these attributes in yourself. If you are lacking in any area, there are opportunities for personal and professional growth. You can attend conferences (such as the AAACN Annual Conference), read journals, attain certification and self-reflect to develop your attributes as a telephone triage nurse. References Cambridge Dictionary. (2011). Common sense. Retrieved from Yıldırım, B., & Özkahraman, Ş. (2011). Critical thinking in nursing process and education. International Journal of Humanities and Social Science, 1(13), Kathryn Koehne, RNC-TNP, is a Nursing Systems Specialist, Department of Nursing, Gundersen Lutheran Health Systems, and a Professional Educator, Telephone Triage Consulting, Inc. She can be contacted at krkoehne@gundluth.org Nurses Wanted: Largest Women s Health Study Seeks 100,000 Nurses Nurses Health Study Recruits Next Generation From the dangers of tobacco and trans fats to the benefits of physical activity and whole grains, much of what we know about health today is thanks to the Nurses Health Study. Researchers are recruiting 100,000 nurses and nursing students to join the long-running Nurses Health Study and expand its landmark research on women s health. Female RNs, LPNs, and nursing students between the ages of 20 and 46 who live in the U.S. or Canada are eligible to join the study. More than 25,000 have signed up already, and recruitment will stay open until the goal of 100,000 participants is reached. Researchers hope to engage a highly diverse group of women in the next generation of the study. For the first time, nursing students are eligible to enroll. In order to make participation as convenient as possible for busy women, participants can join online and complete the study s surveys through a secure website, More than 250,000 nurses have participated in the study since the 1970s. By completing confidential lifestyle surveys, they have helped advance medical knowledge about nutrition, exercise, cancer, heart disease, and many other conditions. Nurses were originally recruited for their expertise in accurately reporting health data, explains Dr. Walter Willett, the study s lead researcher and Chair of the Nutrition Department at Harvard School of Public Health in Boston, Mass. Their involvement has been invaluable, and their dedication is remarkable an astounding 90% of them are still enrolled, decades later! The new group, NHS3, will allow us to understand how today s lifestyle and environment affect a woman s health in the future. Nurses enrolled in the earlier studies are encouraging their daughters and younger colleagues to join. My mom started filling out surveys when the study began, one nurse recently commented on the NHS3 Facebook page ( I am so proud to be part of this study and see what it has done. LVM Systems, Inc E. Florian Avenue, Mesa, AZ Corporate members receive recognition in ViewPoint, on AAACN's Web site, and in various conference-related publications, as well as priority booth placement at AAACN's Annual Conference. For more information about Corporate Member benefits and fees, please contact Marketing Director Tom Greene at greenet@ajj.com or Call for Member News In the new "From Our Members" column, we welcome short submissions and photos from members who wish to share their nursing stories and experiences, practice innovations, and lessons learned. Submissions should be no more than 600 words and ed to katie@ajj.com for consideration. 15

16 Cynthia Cyrus Member Appointed as HIMSS Representative AAACN member Cynthia W. Cyrus, RN, BSN, MBA, has been appointed to serve as the Organizational Affiliate representative to the Health Information and Management Systems Society (HIMSS). Cynthia is Project Manager, Innovation Integration Center at Vanderbilt Medical Group, Nashville, TN. Cynthia will review information being disseminated by HIMSS and keep AAACN leadership and members apprised of the relevance to ambulatory care nursing. Site Licenses Help Employers Educate Groups of Nurses Both the Ambulatory Care Nursing Certification Review Course and the Telehealth Nursing Practice Core Course (TNPCC) can be offered to groups of 25 or more nurses through the purchase of a site license. A site license permits nurses to take the course at their own pace by accessing the course in the AAACN Online Library. Once a nurse completes the course, she or he will be awarded contact hour credit. The cost for up to 25 nurses is $2,000. The price increases based on the number of users. Facilities that are promoting certification to groups of nurses or have nurses new to telehealth who could benefit from the courses may wish to explore purchasing a site license by contacting Pat Reichart at pat@ajj.com or by calling Members Helped AAACN Grow in 2011 The 2011 Member-Get-a-Member campaign added 77 new members to our roster. Last year, 68 current members recruited their colleagues by letting them know why they belong to AAACN and the benefits they enjoy. During the campaign, a monthly winner was drawn each month and that recruiter received a $50 AAACN gift certificate. At the end of the campaign, members Eileen Esposito and Carol Rutenberg had recruited three or more members, making them eligible to win a $100 AAACN gift certificate. Bonnie Richter s name was drawn as the winner of a free 2-year membership renewal. The winner of the top prize was Sharon McAllister from Saudi Arabia. She recruited five of her colleagues! Sharon won complimentary registration to the 2012 conference. AAACN welcomes these 77 new members and sends our special thanks to those members who did the recruiting: Edhelpia Monje Agati Flora May Alidon Mary Anderson Jermaine Antivola Amy Aparicio Leonida Ayangco Amy Bacon Rebecca Burke Meredith Cotton Christine Dailey Mary Holfester Daly Twila Darnell Josephine Debnar Susan Deering Teresa Dijamco Mattie Ely Vanessa Flores Mary Fortunato-Habib Janet Fuchs Linda Gemeiner Julie Godfrey Maryann Grottano Annette Hamlin Malinda Hanania Jeannette Hausladen Brenda Haynes Katherine Herrmann Mary Holmes Carol Johnson Jane Johnson Barry Kandell Kim Kish Jennifer Laird Linda Lawson Ellie Leonard Michele Lizzi Deana Lovelace Allison Lupo Marion Marino Lancelot Marr Sylvia McKenzie Marguerite Mignone Mary Morin Marilyn Morrisse Kaitlin Mussomeli Radhika Nandlal Jerry O Leary Debora Oliver Dawn Olmsted Kiersten Osterchrist Joyce Panacci Cshalla Parker Anja Peersen Kate Piotrzkowski Anthony Putney Anita Reed Heidi Regan Bonnie Richter Cynthia Rodrigues Diane Rolf June Rondinelli Michele Rothman Junghwa Ryoo Catherine Scantlan Renee Scott Lori Sharp Stephanie Skinner Gloria Staley Cynthia Standish Susan Stirling Karol Stirneman Lisa Swerczek Christine Torre Cheryl Weimer Mackenzie Williams Theresa Wilmot Mary Winkfield The 2012 campaign kicks off April 1. Download a membership application from the Web site ( fill in your name in the Who referred you to AAACN? section at the bottom, and distribute to colleagues. You can also ask colleagues to insert your name in the Referred By section of the membership application if they join online. You could be a winner of a certificate, a two-year membership, or complimentary registration to the 2013 conference in Las Vegas! 16 ViewPoint MARCH/APRIL 2012

17 ViewPoint Article Wish List ViewPoint features articles on a variety of topics of interest to ambulatory care and telehealth nurses. The following wish list includes topics members have told us they d like to read more about, and now we re hoping you can share your experience and knowledge with other members! Ambulatory care staffing ratios Ambulatory pediatrics Bariatrics Case management College health Disease management Immunizations Leadership in nursing education Legal nurse consulting Magnet process for ambulatory Medical home model Metrics for ambulatory care nursing Patient safety RN leadership Staff education Staffing/competencies in specialty clinics Travel medicine If you or someone you know would like to write an article on a wish list topic, complete the Author Interest Form at (click Publications > ViewPoint). Virtually Attend AAACN s 37th Annual Conference If you are unable to attend the Orlando conference, you can still learn from the fantastic sessions. The audio recordings and handouts from all sessions offered at the conference will be available for purchase in early June in the AAACN Online Library at You may purchase individual sessions or a package that includes all sessions. Each session you purchase includes the accompanying contact hours. Once you make a purchase, you have permanent access to those sessions. Past conferences, ViewPoint articles, and webinars are also in the library. We encourage you to browse the Online Library for topics of interest to you. If you know someone who attended the conference, ask if they will share their content with you! Conference attendees can each offer access to the conference sessions to two colleagues for free. 17

18 AAACN Membership Speaks Out on Health Care Reform An objective under Goal 1 of the AAACN Strategic Plan, Serve our Members, is to inform and engage members about health care reform (HCR). In November 2011, members of AAACN were given the opportunity to respond to a survey on the impact of HCR. The elevenquestion survey was sent out to members via SurveyMonkey. The intent of the survey was threefold: to understand the level of impact HCR has on our members, identify the elements of HCR in which members are currently involved and their willingness to share experience, and evaluate how well members feel AAACN is supporting their HCR needs. The survey, sent to 2,302 members, had a response rate of 6.8%, with 156 members starting the survey and 132 members completing. Below is a summary of the responses to 11 survey questions. One What effect does health care reform have on practice? Fifty-three percent of those who answered said that HCR is having a moderate impact on their practice. Two In what elements of HCR are members institutions or facilities involved? Seventy-eight percent of respondents are involved in Meaningful Use, 71% in Patient Centered Medical Home, 71.7% in Care Coordination, 57.5% in Readmissions, and 41.6% in Accountable Care Organizations. Three Would members feel they would benefit from participation dedicated to HCR via discussion board? Approximately 50% of those responding showed interest. Four What HCR topics would be of interest for the discussion board? Patient Centered Medical Home, RN Role, Care Coordination, Accountable Care Organizations, EMR, Readmissions, Military/Veterans issues, and Reimbursement were mentioned with the most frequency. About half of those responding said they would participate in online discussion of relevant health care reform topics. Five Have you visited the HCR page on the AAACN Web site ( that was added in July 2010? According to the survey, only 27.1% of respondents were aware that this robust member resource existed. Six Is the content on the HCR Web site valuable? Fifty-five percent found the content to be very valuable and 44% percent found it to be moderately valuable. Seven Why haven t you been taking advantage of the HCR online content? Most respondents said they were either unaware that the Web page existed or that time limitations kept them from accessing this information. Eight Any suggestions for other resources for the AAACN Web site? Nine individuals responded to this question. Their suggestions were: National Database of Nursing Quality Indicators (NDNQI), Patient Centered Medical Home Updates, healthleaders.com, AIDS administration, and any positive impact of HCR for patients. Nine If you re currently implementing change, would you be willing to share your expertise and if so, in what way? Twenty-three members indicated they would be interested in participating. Ten Please provide contact information so you can be reached to discuss your experience and/or expertise. Thirty-eight members provided their contact information. Many also provided AAACN with ways in which they would be willing to share, such as webinars, ViewPoint articles, and participation on a HCR Expert Panel. About half of the respondents said they would participate in online discussion of relevant health care reform topics. The main HCR concerns of our members are medical home, the role of the RN, reimbursement, care coordination, and issues affecting military personnel. Eleven How can AAACN enhance the learning needs of members? The majority of those responding to the survey encouraged AAACN to continue to provide information on HCR through annual conference, Web site, ViewPoint, e-newsletters, and webinars. In an effort to swiftly respond to the results of HCR survey, AAACN Post Your Health Care Reform Comments and Questions Member Jan Fuchs, MBA, MSN, NEA-BC, recently accepted the responsibility to monitor posts in the online Health Care Reform Forum ( Jan completed her Health Care MBA and is fascinated by health care policy. She has been actively involved in legislation in Ohio and is part of a group working to remove barriers to health care delivery. Members are encouraged to post their comments and questions via the Forum. The Forum is another way AAACN is providing networking opportunities to assist you with implementing the required changes related to health care reform. Visit the online forum today! 18 ViewPoint MARCH/APRIL 2012

19 has taken action. The Health Care Reform Forum, part of the HCR site ( provides members with the opportunity to post their thoughts and ideas on HCR. Recently, a volunteer opportunity to monitor this discussion was sent out to members. Janet Fuchs, MBA, MSN, NEA-BC, Senior Director of Ambulatory Nursing with Cleveland Clinic, has recently been appointed to this volunteer role. Secondly, the association has already begun to contact those willing to share expertise to discuss plans to share their expertise with their colleagues. Finally, because so many respondents were unaware of the HCR page on the AAACN site, we want to be sure you know the page is accessible through a link reading HC Reform, which is located on the blue banner at the top of the AAACN home page. In just one click, you will be able to access the Health Care Reform Forum and many other HCR resources. Thank you for providing thoughtful feedback. From the survey, we know many of our members are actively involved in health care reform initiatives and have experiences they would like to share with their colleagues. Your responses also validate the need for your professional organization to continue to inform and engage members about health care reform. AAACN is committed to serving our members and will continue to follow through with this very relevant strategic plan objective! Suzanne N. Wells, BSN, RN, is Manager, Answer Line, St. Louis Children's Hospital, St. Louis, MO, and American Academy of Ambulatory Care Nursing President-Elect. She can be contacted at snw4713@bjc.org Col. Carol Andrews, USAF, NC, MA, RN-BC, NE-BC, CCP, is Director, MAJCOM-AFMOA Team for Requirements and Information X-fer (MATRIX), United States Air Force, San Antonio, TX, and American Academy of Ambulatory Care Nursing Director. She can be contacted at candrews3@patriots.uttyler.edu Coming soon in Educational offerings: Lyme Disease: The Great Imitator 37th Annual Conference Photo Highlights Plus these favorite columns: Telehealth Trials and Triumphs Health Care Reform For Your Health Member Spotlight From Our Members Patricia M. Grady, BSN, RN, CRNS, FABC, is currently the Associate Chief Nursing Officer and Executive Director of Lahey Clinic Medical Center, North Shore Ambulatory Practice and Ambulatory Operations, Peabody, MA. Her dynamic role supports the advancement of organizational strategic requirements for clinical quality and safety practices, patient satisfaction, employee engagement to research, development and execution of outcome-oriented health care product lines, business plan development, and project management. She also achieved the status of an Advisory Board Company Fellow in Business. When Pattie was selected as Administrator of a standalone ambulatory care center, she was tasked with transforming the culture to an updated clinical practice with an integrated model of care. It was during the $40 million design and building project for a new ambulatory care center that Pattie first recognized the need to join AAACN. Her desire was to support the advancement of evidence-based ambulatory clinical practice; however, it was the multitude of AAACN resources that she had access to as a member which helped her achieve her goals of successful practice outcomes. Her leadership team, staff, and providers were competent and happy. The most valuable aspect of AAACN membership to Pattie is her ability to network with fellow leaders in advancing the integrated model of the ambulatory care practice. The majority of Pattie s practice and leadership experiences have been in the ambulatory care sector. She s had the opportunity to truly advance ambulatory nursingled strategies to create positive quality outcomes for patients, families, health care organizations, and the health insurance industry. According to Pattie, The heart of all I focus on every day is ensuring the delivery of the highest quality and safety of patient and family-centered care at the lowest cost. Currently, Pattie supports the research of the AAACN Care Coordination Literature Review Team in developing national care coordination competencies for the ambulatory care nurse. Pattie wants everyone to know that she is the proud mother of two fabulous sons, Mark and Matthew, and very fortunate to be married 29 years to her wonderful husband, Mark. On a career-focused note, she is currently leading the research and development of the Nurse Care Coordinator role with aligned evidence-based tools as Lahey Clinic rolls out their Patient Centered Medical Home program. While Pattie is still developing her future career plans, she encourages all of us to share the benefits of AAACN membership with ambulatory care nurses everywhere. Deborah A. Smith, RN, DNP, is an Associate Professor, Georgia Health Sciences University, College of Nursing, Augusta, GA, and Editor of the Member Spotlight column. If you would like to be featured in Member Spotlight, contact Deborah at dsmith@georgia health.edu 19

20 East Holly Avenue, Box 56 Pitman, NJ Volume 34, Number 2 CHANGE SERVICE REQUESTED Presorted Standard U.S. Postage PAID Deptford, NJ Permit #142 ViewPoint is published by the American Academy of Ambulatory Care Nursing (AAACN) AAACN Board of Directors President Linda Brixey, RN President-Elect Suzanne (Suzi) N. Wells, BSN, RN Immediate Past President Traci Haynes, MSN, RN, BA, CEN Director/Secretary Mary Vinson, DNP, RN-BC, CMPE Director/Treasurer Susan M. Paschke, MSN, RN-BC, NEA-BC Directors Col. Carol Andrews, MS, RN-C, BC, CNA Judy Dawson-Jones, MPH, BSN, RN Barbara Pacca, BSN, RN, CPN Executive Director Cynthia Nowicki Hnatiuk, EdD, RN, CAE Director, Association Services Patricia Reichart AAACN ViewPoint Editor Kitty M. Shulman, MSN, RN-BC Issue Editor Patricia (Tricia) Chambers, BHScN, DC, RN Editorial Board Carol Ann Attwood, MLS, AHIP, MPH, RN,C Virginia Forbes, MSN, RN, NE-C, BC Liz Greenberg, PhD, RNC Jerry A. Mansfield, PhD, RN Laura Morano, RN, CPN, MA Susan M. Paschke, MSN, RN-BC, NEA-BC Ginger H. Whitlock, RN, MSN, CNA Manuscript Review Panel Irene Berg, MSN, RN-BC Patricia L. Jensen, MSN, RN Vannesia D. Morgan-Smith, MGA, RN, NE-BC Becky Pyle, MS, RN Janice Tuxbury, DNP, FNP-BC Managing Editor Katie R. Brownlow, ELS Editorial Coordinator Joe Tonzelli Layout Designer Bob Taylor Education Director Rosemarie Marmion, MSN, RN-BC, NE-BC Marketing Director Tom Greene AAACN is a welcoming, unifying community for registered nurses in all ambulatory care settings. Our mission is to advance the art and science of ambulatory care nursing. Call for Abstracts for 2013 Conference invite you to submit Wean oral or poster abstract for the 38 th Annual AAACN Conference, April 23-26, 2013, at the Las Vegas Hotel and Casino. Share your expertise, new practice initiatives or techniques, best practices, or research with colleagues. Presenters receive $100 off their registration fee. Oral presenters receive an honorarium. The deadline for oral presentations is May 15, 2012, the poster deadline is December 15, Obtain the oral and poster criteria from the Events section of the Web site at AJJ-0412-V-2M Copyright 2012 by AAACN