Michigan Renewal Bundle – Part 3

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The following course content

This Michigan License Renewal Bundle is broken down into 3 parts as per the requirement for Michigan Nurses which states: No more than 12 contact hours may be completed in a day.

This Part 3 features multiple interesting topics in one easy course, upon completion of this course, you will receive a certificate for 7 contact hours.
This part does not include the state-required topics for renewal – Part 1 contains those.

Course Outline

1. PTSD in Nurses
2. End of Life Process
3. Sexual Harassment Prevention
4. Following a DNR: An Ethical Dilemma in Nursing
5. Screening for Suicide Risk Factors in Pediatrics

PTSD in Nurses

Introduction

Post-Traumatic Stress Disorder (PTSD) gained recognition from its association with Military Veterans in the Vietnam War emotional strain from the events they witnessed after returning home from war. Names like “shell shocked” or “combat fatigue” were used to describe the Veterans upon their return. In 1980, the Diagnostic and Statistical Manual of Mental Health Disorders, developed by the American Psychiatric Association, officially identified this condition as a psychological disorder (4).  

Although anyone can experience PTSD, healthcare professionals have an increased risk of presenting with this disorder. Year 2020 has most likely been the most s most stressful year for many people. Many have lost their income, family, homes, and sense of well-being. Emergency personnel, rescue workers, physicians, and nurses have all voiced how COVID-19 has had a terrible impact on everyone. The increase in hospitalization and deaths has caused a major increase in Post-Traumatic Stress Disorder Diagnosis (PTSD) among the general population and healthcare professionals. In this course, we will discuss strategies that healthcare professionals can utilize to promote successful identification and coping mechanisms for PTSD. 

Healthcare professionals practice in an environment that is extremely high stressed, demanding, and unpredictable. Nurses, physicians, and other healthcare professionals are continuously exposed to physical, psychological, and mental hazards for upward of 12-16 hours a day. Each person reacts and responds to extreme stress and trauma in various ways. Since there are so many variables to consider, it has been difficult to diagnose PTSD in healthcare professionals.  

It is natural for individuals to experience fear, heightened senses, and avoidance after experiencing a traumatic event. Healthcare professionals are aware of the “fight or flight” response – our body’s natural defense to our sense of danger or fear. Everyone has an individual definition of trauma. For some people losing a loved one is considered a traumatic event. For others, the definition of a traumatic event may be coming in contact with an immediate threat on their personal life or witnessing a dangerous situation. When does it turn into PTSD? To understand that question we must first define PTSD. 

Case Study

Laura is a 26-year-old new nurse of five years that has decided to take a job doing traveling nursing to help with the overwhelming demand of taking care of COVID-19 patients. She is offered a wonderful opportunity to make a difference. The travel agency offers her a staff nurse position taking care of two patients in the critical care unit. She will work 13 weeks at 36 hours weekly on nights. Her pay is 5,000 per week plus a non-tax stipend for her lodging and meals. She accepts the position and takes leave from her full-time position. She leaves behind her pet dog as she prepares to go to California from Tennessee to begin working at the hospital. The agency contacts her to tell her they will also provide transportation to and from her residence to the hospital at no charge.  

Laura arrives in California and reports to the hospital department where she will work. After speaking with the nurse manager, Laura is told that her assignments have changed, and she will still work in the critical care unit but will care for at least seven patients who have COVID-19 because they are so short-staffed. Laura is confused and does not really know if she can say no to the assignments because of her contract. She tries to contact her agency, but no one can take her call. She leaves a message in hopes that someone will return her call. Laura is expected to start work that same evening. She is a little hesitant but reports to duty as scheduled. 

Laura's first night is horrific. She must care for seven patients who have COVID-19. The patients are all on ventilators and no one is available as a resource for her to ask questions. The entire environment is overwhelming. Patients are lined against the wall, people are crying, a code red is called every 10 to 15 minutes, and most of the time the patient dies. The morgue is overflowing and some of the deceased patients are placed in body bags and lined against the wall. After three shifts Laura decides she cannot fulfill this contract because she has no support. Lately, she is experiencing nightmares, feels very agitated and anxious, and cries all the time.  

Laura reaches out to her agency and informs them of her decision, but she is informed that if she breaks the contract, she will be reported to the board of nursing for job abandonment. Laura decides to stay to fulfill the contract. Laura also notices some of her co-workers are manifesting a change in behavior. They have become increasingly sad, detached from others, and anxious. They are also displaying anger toward other staff members. Laura feels the environment is toxic and wishes she were anywhere but there. 

Refer to this case study to answer some questions throughout the course. 

Definition 

Post-traumatic stress disorder is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event (1). 

The DSM-5 diagnostic criteria for PTSD include: 

A. Stressor (one required):  

• Personally experiencing trauma or watching someone endure it. 
• Learning that a traumatic event(s) may have occurred to a close family member or friend. 
• In cases of life-threatening instances, or the death of a family member/friend, the event(s) must have been violent or accidental.  
• Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. nurses working in critical care units, caring for COVID-19 patients, etc.) (2). 

B. Intrusion symptom (one or more required):  

• Recurrent and distressing memories or dreams of the trauma experienced. 
• A dissociative reaction in which the person is completely unaware of their surroundings.  
• Intense, prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
• Distinct physiological reactions of internal or external reminders that may represent any aspect of the traumatic event (2). 

C. Avoidance (one or both required): Avoiding any memories, thoughts, or feelings related to the traumatic event on a continuous basis.  

• Avoidance or efforts to avoid instances or items that resemble or remind the person of the traumatic event. Examples include (2): 
• People 
• Places 
• Activities 
• Conversations 
• Familial objects 

D. Negative alteration in cognition and mood (two required):  

• Inability to remember specifics of the traumatic event due to dissociative symptoms.  
• Persistent and over-exaggerated negative belief about oneself, others, or the world (e.g. “the world is completely dangerous” or “my whole nervous system is shot”).  
• Persistent negative emotional state (e.g. fear, anger, guilt, or shame).  
• Persistent distorted perception about the cause of the traumatic event leads an individual to blame themselves. 
• Distinctive or diminished interest or participation in any significant activities. Feelings of detachment from others. Continuous inability to experience positive emotions (2). 

E. Alterations in arousal and reactivity (two or more): 

• Angry outbursts and irritable behavior without provocation, leading to physical aggression toward people or objects.  
• Self-destructive reckless behavior. 
• Hypervigilance. 
• Exaggerated startle response. 
• Problems with concentrating. 
• Sleep disturbance (2). 

F. Duration of the disturbance (criteria B, C, D, and E required):  

• More than a month. 

G. Functional Significance (required): 

• Clinically significant distress caused by the traumatic event(s) or impairment in social, occupational, or other areas of functioning.  
• The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2). 

Case Study 

Post-Traumatic Stress Disorder (PTSD) is defined as a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape (1). PTSD also can occur in people who have been threatened with death, experienced sexual violence, sustained a serious injury, continuously works in a highly stressful environment (such as a hospital), or feel helpless in assisting those that have been placed in their care (1). 

The DSM-5 diagnostic criteria for PTSD includes the following. 

Stressor: (one required) 

• Experiencing trauma 
• Watching some type of trauma as it occurs to others 
• Learning that the traumatic event(s) may have occurred to a close family member or close friend.  
• Actual or threatened death of a family member or friend (the event or events must have been violent or accidental).  
• Experiencing repeated excessive exposure to adverse effects of a traumatic event (e.g. healthcare professionals working in critical care units, nurses, physicians, paramedics caring for COVID-19 patients) (2). 

Intrusion Symptom: (one or more required) 

• Recurrent and distressing memories of the trauma experienced 
• Recurrent and distressing dreams related to the traumatic event.  
• Dissociative reaction in which the person is completely unaware of their surroundings. 
• Intense prolonged psychological exposure to internal or external cues that may resemble the traumatic event.  
• Distinct physiological reactions of internal or external reminder that may represent any aspect of the traumatic event (2). 

Avoidance: (one or both required) 

• Avoiding any memories, thoughts, or feelings related to the traumatic event.  
• Avoidance or efforts to avoid people, places, activities, conversation, or familial objects that may be a reminder of the traumatic event (2). 

Negative Alteration in Cognition and Mood (two required) 

• Inability to remember any aspect of the traumatic event due to dissociative symptoms.  

• Persistent overexaggerated negative belief about oneself, others or the world (e.g. such as the world is completely dangerous or my whole nervous system is shot).  
• Persistent negative emotional state (e.g. fear, anger, guilt or shame).  
• Persistent distorted perception about the cause of the traumatic event that leads an individual to blame themselves.  
• Distinctive or diminished interest or participation in any significant activities.  
• Feelings of detachment from others.  
• Continuous inability to experience positive emotions (2). 

Alterations in Arousal and Reactivity (two or more) 

• Angry outbursts and irritable behavior without provocation, leading to physical aggression towards people or objects.  
• Self-destructive reckless behavior.  
• Hyper vigilance.  
• Exaggerated startle response.  
• Problems with concentrating.  
• Sleep disturbance (2). 

Duration of the Disturbance (Criteria B, C, D, and E required) 

More than a month 

Functional Significance (required) 

• Clinically significant distress caused by the traumatic events or impairment in social, occupational, or other areas of functioning. The functional disturbance is not attributable to the psychological effects of a substance or any other medical condition (2) 

Sign and Symptoms 

There are many signs and symptoms of PTSD. Symptoms may develop immediately or within three months of the traumatic event(s). On some occasions, a person can suppress their feelings for up to a year before remembering a traumatic event. These signs and symptoms are grouped into four categories: intrusive memories, avoidance, negative changes in mood and thinking, and negative changes in physical and emotional reactions (3).  

Intrusive Memories 

Intrusive memories include recurrent distressing memories of the traumatic event, flashbacks, nightmares, severe emotional distress, or a physical reaction to something that reminds you of the traumatic event (3) 

Avoidance  

Avoidance includes cognitively trying to avoid thinking about the traumatic event and avoiding places, activities, conversations, tangible items, and people that reminds you of the traumatic event (3) 

Negative Changes in Mood and Thinking 

Negative changes in mood and thinking include feelings of hopelessness about the future, memory problems including not remembering certain aspects of the traumatic event, difficulty in maintaining close relationships, feeling of detachment, lack of interest in activities once enjoyed, difficulty experiencing positive emotions, feeling emotionally numb, alcohol abuse, drug abuse, having negative thoughts about yourself or other people around you or the world in general (3).   

Changes in Physical and Emotional Reactions 

Changes in physical and emotional reactions include being easily startled or frightened, always being on guard for danger, insomnia, trouble concentrating, overwhelming feelings of guilt or shame, increased irritability, aggressive behavior, angry outburst with no provocation, chronic illnesses, gastrointestinal problems, angina, self-destructive behavior, sweating/shaking, heightened “fight or flight” syndrome, pain, depression, hallucinations, anxiety, and feelings of constant sorrow (3). 

Types of PTSD 

Since we know that the American Psychiatric Association describes PTSD as an anxiety disorder, we know there are different types and severity of PTSD. The types of PTSD are categorized according to the severity of the symptoms to help with the diagnosis. There are five types of PTSD which include: Normal stress response, Acute Stress disorder, Uncomplicated PTSD, Complex PTSD, and Comorbid PTSD (5). 

Normal Stress Response 

The normal stress response, the “fight or flight” syndrome is the precursor to PTSD, and it does not always lead to full blown PTSD. Any event that causes the natural stress response (such as surgery, an injury, or pending thoughts of danger), initiates a normal stress response. The problem occurs when this response is not alleviated within a short amount of time. 

Acute Stress Disorder 

A life-threatening event such as job loss, illness, natural disaster, or death of loved one can initiate this early form of PTSD. While the individual may experience this type of disorder, the individual will usually overcome the initial stressor. If it becomes prolonged and untreated, it can lead to full blown PTSD. 

Uncomplicated PTSD 

This type of PTSD is associated with one major event which makes it the easiest form of PTSD to treat. The individual will want to avoid anything that may remind them of the event. 

Complex PTSD 

Complex PTSD is just as the name implies. This type of PTSD is associated with multiple traumatic events and is usually associated with various types of abuse, violence, war, and traumatic losses. The unfortunate problem with diagnosing this type of PTSD is that some health care professionals confuse it with borderline or antisocial personality disorder or dissociative disorders (5). 

Comorbid PTSD 

This type of PTSD is associated with a person that has more than one mental health concern along with substance or narcotic misuse issues at the same time. This condition is extremely common because most people have more than one problem. What makes this type of PTSD more complicated to treat is the fact that individuals try to self-medicate because they are in denial, but this only leads to self-loathing and self-destructive behaviors (5). 

Phases of PTSD in Nurses 

There are four phases of PTSD identified by Pyramid Health. The phases are the impact phase (emergency), rescue phase, the intermediate recovery phase and the long-term reconstruction phase (6). 

Impact Phase (Emergency) 

The impact phase consists of the initial reaction such as anxiety, helplessness, guilt, shock, or fear. This is the first phase which occurs immediately after the individual experiences the traumatic event. The length of time the individuals stays in this phase depends on the severity of the traumatic event (6). 

Rescue Phase 

The rescue phase involves the affected person being able to come to terms with what has happened. This phase is closely related to the acceptance phase in grieving. The individual may experience flashbacks, confusion, anxiety, denial, or feelings of despair. 

Intermediate Recovery Phase 

The intermediate recovery phase is associated with the individual making the adjustment to return to normal everyday life. In this phase, the individual can begin to look at other issues within their life. While they are addressing new issues, they may have the feeling of altruism in which they feel the love and support from others which gives them the sense that they can also help others. They may also develop the feeling of disillusionment in which they feel overwhelmed because they are not receiving the love and support they think they should, or when the love and support ends, they realize they are on their own. This phase is also closely related to the acceptance phase in grieving. As with the grieving phase the individual may go back and forth between phases. 

Long-term Reconstruction Phase 

The long-term reconstruction phase is characterized by the individual being able to rebuild while dealing with the trauma's aftermath. Their main concern is about their future and how they can maintain healing. 

Causes of PTSD 

Defining the causes of PTSD can be quite difficult because physicians have not been able to determine why some individuals may have a different response to the same traumatic event.  Most adults have experienced some stressful experiences that did not cause PTSD. Some causes of and risk factors for PTSD could include inherited mental health risk, an individual's temperament, and even the way our brain regulates chemicals and hormones which release stress in our bodies. 

Considerable evidence links the hippocampus to the representation of contexts by the brain suggesting that the hippocampus has a central role in solving the equivalence problems with respect to content. Tracking moment-to-moment change in input and detecting change sufficient to require altering behavior is crucial to survival. This perspective highlights the critical role of the hippocampus in both spatial cognition, episodic memory tracking change, and detecting boundaries separating context or episode from another. This is very important in people that suffer with PTSD (14).  

The hippocampus is a component of the brain, a part of the lymphatic system that plays a role in the consolidation of information from short-term memory to long-term memory, linking memories to sensations and in spatial memory that enables navigation (9, 14). The hippocampus is located under the cerebral cortex in the allocortex and there are two hippocampi, one on each side of the brain. Post-traumatic stress disorder is associated with abnormal hippocampal activity (9, 14). It has been noted that PTSD is mainly associated with functional and structural changes in the amygdala, medial prefrontal cortex, and the hippocampus (9, 14).  

The two hippocampi have very distinct roles. The posterior hippocampus' main role is in memory retrieval and spatial cognition. The anterior hippocampus role is mainly associated with the amygdala, the hypothalamic-pituitary-adrenal (HPA) axis, and the limbic prefrontal circuitry (9, 14). The anterior hippocampal-amygdala connections are thought to underlie atypical memory processes in PTSD, including flashbacks, intrusive thoughts, and nightmares (9, 14). There are current theories of PTSD that identify hippocampal dysfunction as a key contributor to hallmark symptoms of PTSD (9, 14). 

One common denominator for causes of PTSD is the actual stress an individual goes through when they experience or learn about a life-threatening event, serious injury, sexual assault, childhood physical abuse, being threatened with a weapon, an accident, being exposed repetitively to death, violence, or sickness.  

The outbreak of COVID-19 has caused a rise in PTSD in healthcare professionals. Working tirelessly to care for patients experiencing new health issues caused by COVID-19 has put so much pressure on healthcare professionals trying to save their lives.  

Unfortunately, because there is no cure for COVID-19 and the public does not always follow the guidelines to prevent the spread of COVID-19, paramedics, doctors, nurses, and other healthcare professionals are continuously putting their own and their families’ lives at risk to try and save lives. This amount of pressure has increasingly led to a spike in PTSD among healthcare workers. 

Healthcare workers in critical care, trauma, and the emergency room continuously witness death while operating in a crowded setting and working with an uninterrupted circadian rhythm due to being short staffed. The healthcare workers’ age, years of work experience, family support, marital status, and coping styles along with prior psychiatric history all play a role in the time they may experience PTSD and what type they will experience. The feelings of helplessness that the healthcare worker experiences when trying to care for the patient who has COVID-19 is a major precursor to the development of full-blown PTSD because they may feel conflicted. They want to help their patients get better, but instead they witness them die alone upwards to every five minutes depending on the department in which they are working. 

Prevalence of PTSD Among Healthcare Workers

Based on the current U.S. population, around 7 or 10 of every 100 (7% - 8% people) will have experienced some traumatic event in their lifetime and this equates to approximately 223.4 million people. Of that amount, currently 20% (44.7 million people) suffer from PTSD. About every 10 out of every 100 (10%) women develop PTSD sometimes in their life compared to about four of every 100 (4%) men. This makes women twice as likely to develop PTSD (11). 

Nurses at the forefront during the pandemic are likely to have experienced major trauma. Such traumas included increased (nearly impossible) workloads, poor patient outcomes, and virtually no support system availability. These traumas led to depression. anxiety and increased cases of PTSD (10). 

Healthcare professionals are trained to take care of the needs of their patients and leave their personal feelings at the door. When the shift starts, the healthcare professional suppresses their emotions so they can get through their shift. The problem arises when the shift is over and the healthcare professional may experience a rush of feelings such as anger, guilt, confusion, sadness, sorrow, and grief. Sometimes in extreme cases, they may experience suicidal or homicidal ideations. To mask their emotions, they may turn to drinking, drugs, or destructive behaviors to cope with the day-to-day trauma. 

A 2021 study in Occupational Health and Safety revealed that during the outbreaks of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome coronavirus (MERS-CoV) and COVID- 19, the development of PTSD ranged between 11% and 73.4% with 51.5% of healthcare professionals and nurses scoring above the Event Scale -Revised (IES-R) threshold for PTSD diagnosis. It was also found that healthcare professionals and nurses during the COVID-19 pandemic have had a higher rate of PTSD symptoms (71.5% - 73%) when compared to rates during the SARS outbreak, which were at only 5% (10). 

One study predicted that approximately 10% - 40% of nurses will have a manifestation of PTSD between one and three years after a pandemic. Poor working conditions and the possibility of COVID-19 exposure had a clear negative impact on nurses' mental health, thus increasing the rate of PTSD (12). 

Young female workers, much of the nursing workforce, who lacked social support due to social distancing restrictions were at a higher risk of developing PTSD. In addition to the social distancing protocols, nurses may have experienced further stress due to self-imposed isolation practices to keep their families from exposure to COVID. This contributed to an even greater percentage of nurses being affected by PTSD (13). 

The nurses that experienced PTSD were in leadership roles, possessed a negative perception of patient care, lacked supportive relationships to work and at home, experienced longterm patient suffering and internalized patient suffering, experienced lack of staffing frequently and lack of organizational support (15). Post-traumatic stress disorder is highly prevalent among healthcare professionals during and after a pandemic, disaster, or tragic event.  

Global Impact

The current outbreak of the COVID-19 infection and the surgency of new mutant strains from the original strand has spread around the world and caused great concern for global and mental health. This current virus, like others before it, has caused an increase in anxiety, stress, economic decline, anger, and most of all fear. This virus has likely touched everyone in the world in some form or fashion due to the isolation that had become the norm.  

While reportedly 92,026,654 people have recovered from the virus, there are long-lasting effects they now must live with whether physical or mental (16). The sheer numbers can cause panic in healthcare professionals. 

In 2003, the SARS-CoV outbreak in Singapore caused a rise of PTSD by 27%. After the 2015 MERS Korean outbreak, the Ebola outbreak in Sierra Leone in 2014 and the Ebola outbreak in 2015 in the Democratic Republic of the Congo, the cases of PTSD in healthcare workers increased significantly because they were on the front lines and had heighten symptoms (17).  

A multinational study that included 906 healthcare workers across the globe taking care of patients who had COVID-19 concluded that the healthcare workers that participated screened positive for moderate to severe depression (5.3%) and moderate to extremely severe stress (3.8%). The prevalence of physical and psychological symptoms such as stress, depression, anxiety leading to PTSD were increased in the healthcare workers (18). 

A study conducted in China revealed that the prevalence of depression, anxiety, and PTSD was estimated at 15.0%, 27.1%, and 9.8%, respectively due to the fear of contracting the virus themselves and death (19). Numerous studies are available that have shown how PTSD is currently on the rise due to COVID-19. There are other traumatic events occurring, but COVID-19 has caused a drastic increase in PTSD symptoms, especially in healthcare professionals. Having to care for patients with COVID-19 while trying to protect your own health and the health of your loved ones can evoke increased stress, anxiety, fear, and feelings of hopelessness in the daily work environment and at home. Some healthcare professionals have had to walk away from the profession they genuinely love.  

For those who have decided to stay in the profession, the need for treatment is the main priority. Before a healthcare professional can help their patients, they must first care for themselves because without proper treatment, they may cause a cascade of tragic events to occur. There may be an increase in medication errors, possible patient abuse, neglect, or procedural mishaps. 

Current Therapy

Post-Traumatic Stress Disorder (PTSD) will get worse without treatment. The Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) in 2017 each establish treatment guidelines for PTSD, which are recommended for treatment of PTSD (20). Current treatment strategies for control of trauma associated symptoms of PTSD have recently been updated by the Veterans Affairs (VA) and the Department of Defense (DoD) after over a decade of dedicated research (21). Both guidelines recommend the use of Prolong Exposure (PE), Cognitive Processing Therapy (CPT) and trauma focused Cognitive Behavioral Therapy (CBT).

The reason why there is strong support for these therapies is because these treatments are evidence-based and trauma-focused. This means they directly address the individual’s memories, feelings, and thoughts related to the traumatic event. These therapies are currently the gold standard for treatment. Eye Movement Desensitization and Reprocessing (EMDR) therapy is also trauma-focused therapy (20, 21). Non-trauma-focused treatments include medication and relaxation therapy.

Prolong Exposure

Prolonged exposure (PE) is strongly recommended by both the APA and VA/DoD as successful treatment for PTSD. Prolonged exposure is based on emotional processing theory which states that traumatic events are not processed emotionally at the time of the event. Theory goes on to suggest that fear is represented in the memory as a cognitive structure that includes representation of the feared stimuli, the meaning associated with the stimuli, and the responses to the stimuli. Prolonged exposure therapy consists of a patient being instructed by a therapist to confront traumatic memories and expose themselves continuously to fearful stimuli with the goal of reaching habituation or extinction.

Some therapists believe that prolonged exposure tends to activate higher rates of fear in individuals suffering with PTSD (21). Psychoeducation about PTSD and the various reactions to trauma, breathing retraining, and vivo and imaginal exposure (two types of exposure) are the main components of prolonged exposure therapy (20). In vivo exposure helps the patient with approaching situations, people, and places they have been avoiding because of the fear response that comes from the traumatic event. This is repeated until the distress decreases.

Imaginal exposure helps the patient to approach the memories, emotions, and thoughts surrounding the traumatic event that they have been avoiding. The patient recounts a narrative of the event in the present tense repeatedly while tape recording themselves as part of homework therapy. Then, the therapist and patient will process the information revealed during the imaginal exposure. This will allow the patient to activate their fear structure and incorporate new information. This process usually takes 8 to 15 sessions (20).

Cognitive Processing Therapy

Cognitive processing therapy (CPT) utilizes social cognition theory and the informed emotional processing theory. Following a traumatic event, usually a survivor attempts to make sense of what has happened and oftentimes it leads to distorted cognitions regarding themselves, the world, and others. According to CPT, people tend to integrate the traumatic event with prior schemas they often assimilate accommodate or over accommodate (20, 21). The main goal of CPT is to shift a person’s belief toward accommodation which is a result of altering their beliefs enough to accommodate a new learning (20, 21). Sessions usually take 12 weeks, and incorporate psychoeducation about the cognitive model and exploration of the patient’s conceptualization of the traumatic event (20, 21).

Cognitive Behavioral Therapy

Trauma -focused CBT is based on behavioral and cognitive models that draw from cognitive behavior theories which include Prolonged Exposure and CPT. The aim of this type of therapy is to modify negative appraisals, correct the auto biographical memory, and remove problematic behaviors and cognitive strategies. It is believed that guilt-associated appraisals tend to evoke negative effects and are usually paired with images and thoughts of the trauma. This causes repeated reconditioned memory of the trauma-producing distress leading to tendencies to suppress or avoid the trauma related stimuli (20, 21). The techniques associated with CBT include exposure and cognitive restructuring.

The exposure technique for a traumatic memory utilizes imaginal exposure, writing about the trauma. and reading the traumatic memory out loud. Treatment for a traumatic-related stimulus usually involves in vivo exposure or instructing patients to identify various triggers of re-experiencing (20). Patients are also taught to practice discrimination of “then verses now “(20). The most important part of cognitive restructuring is teaching patients to identify the various dysfunctional thoughts and erroneous thinking and replace them with rational alternative thoughts and reconsider beliefs about themselves, the trauma, and the world (20).

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Eye Movement Desensitization and Reprocessing (EMDR) is a type of traumatic exposure therapy in which healthcare professionals help the individual make their eyes move back and forth while they imagine the trauma. The EMDR therapy allows for the individual to reprocess the memory while addressing the past, present, and future aspects of the traumatic memory. EMDR can be used to help reduce anxiety and depression associated with PTSD. Therapists have indicated individuals who participated in therapy sessions twice daily (prolonged exposure session in the morning and an EMDR in the evening) were found to have higher satisfaction rates and reduced PTSD symptoms. EMDR has been shown to reduce fear and leave patients feeling relieved and satisfied (21).

Medication Therapy

The current medication therapy recommended by the American Psychological Association for PTSD treatment are paroxetine (Paxil), fluoxetine (Prozac) and venlafaxine (Effexor). Based on the most relevant and recent research, these medications have shown the most benefit as monotherapy in treatment of post-traumatic stress disorder symptomology (21). The relative benefit of using selective serotonin reuptake inhibitors (SSRI) or selective norepinephrine reuptake inhibitors (SNRI) is side effects profiles are generally well tolerated (21). All medications must be customized for everyone because people react differently to medications and their dosages.

Medications that help with PTSD symptoms may be in conjunction with antidepressants. These include:

Clonidine and Guanfacine, Risperidone for agitation

Clonidine, Prazosin and Trazodone for trauma related nightmares

Some beta-blockers (such as Propanol) to decrease hyperarousal symptoms, but it has not been approved by the FDA (21, 22).

Another medication therapy that has grown attention for treatment of PTSD is the Stellate Ganglion Block (SGB) injection. While SGB treatment has been around for a while to treat patients suffering with chronic pain and some neurological problems, it is now being used in the treatment of PTSD. Positive results include improving PTSD symptoms and reducing or eliminating suicidal ideations (23). The procedure is performed under local anesthetics placing the medication at the C6-C7 level guided by ultrasound or x-ray imaging. The injection resets the sympathetic nervous system to its pre-trauma state. The effects can be felt as early as 30 min after injection and can last for years. Research has shown that the overall success rate has averaged 85% - 90% range (23).

Relaxation Therapy

Relaxation therapy is a form of psychotherapy that utilizes breathing techniques, progressive muscle techniques, and meditation and to illicit a voluntary relaxation response of the individual. Sometimes the use of guided imagery is used to help the individual focus on positive mental images. This technique helps lower blood pressure, relieve muscle tension, and lower stress.

Progressive Muscle Relaxation has been used to help reduce fatigue in nurses and relieve PTSD symptoms. This technique involves sequential tensing of major muscles in the body which reduces feelings of tension and lowers perceived stress. Progressive muscle relaxation can be performed anywhere at any time. This technique can decrease the pulse rate, increase the individual’s oxygen saturation, and is sometimes used in conjunction with other forms of psychotherapy (24, 25).

Coping Mechanisms 

For general individuals experiencing PTSD, it is sometimes difficult to cope with the mountain of symptoms that they may experience. For healthcare individuals experiencing PTSD it is critical that they seek treatment and develop coping mechanisms to deal with their symptoms because if they do not, their actions can become detrimental to their patients and themselves. 

There are negative and positive coping mechanisms. Negative coping mechanisms include avoidance, becoming defensive and confrontational, displacement of feelings, suppression, self-isolation, and destructive behavior (25). There are three broad categories of coping responses. They include voluntarily seeking or receiving social support, voluntary strategies of gathering information and rehearsing responses to danger, and involuntary deployment of an unconscious homeostatic mechanism that reduces the disorganizing effects of sudden stresses (25, 26). 

Healthcare professionals have resources available to help them cope with PTSD. Some workplaces have elicited the help of a psychiatrist or psychologist to provide drop-in services at the work site. Various positive coping mechanisms include: 

• Spiritual guidance in prayer 
• A strong support system to lean on such as a sponsor that the individual can call when feeling overwhelmed 
• Including family in the healing process 
• Performing mindful meditation (one of the newest forms of coping mechanisms for PTSD which encompasses a form of meditation in which the individual focuses on current sensations and feelings without applying any thoughts to them. This results in mental clarity and reduction of stress.  

Moral resilience describes when an individual can confront distressful and uncertain situations with courage and confidence while relying on a strong system of values and beliefs. Moral resilience helps keep the individual “in check,” which allows their mind to conceptualize the situation, knowing when events are out of their own control. Moral resilience must be gradually built and developed by an individual and requires persistence and experience (26). Nurses should focus on developing moral resistance when caring for patients.  

Other positive coping mechanisms include yoga, relaxation techniques, guided imagery to focus on positive thoughts when the stressors resurface, prescription medication for PTSD, peer support at work, professional counseling, group therapy, tai chi, and developing a hobby.

Conclusion

Post-traumatic stress disorder can be a very debilitating condition. PTSD affects millions of people a year during non-pandemic crises. This condition nearly doubles during pandemic crises, especially for healthcare professionals. Healthcare professionals are the first line of help for the public. In order for them to do their jobs effectively, mental health must be a top priority. COVID-19 has caused an increased level of PTSD in healthcare professionals. As we watch colleagues, strangers, and loved ones battle with or succumb to COVID-19, we may find ourselves feeling hopeless and wanting to leave the profession we love. 

Health care professionals develop a bond with their patients as well as their colleagues. It is that bond that gives some people more purpose than others and helps them to get through PTSD. Healthcare workers must receive the help that they need so that they can continue to help their patients.  

Many organizations now offer counseling, time off, peer support, and incentives for healthcare professionals who engage in self-care. Proper treatment can alleviate or control PTSD in healthcare workers. Our goal in the future is to continue to make the physical health, spiritual health, and mental health of all healthcare workers top priority so we can continue to give the best care to everyone who comes to us for help. 

End of Life Process

End of Life Process

Introduction   

Have you ever cared for someone who was dying, known someone who was in hospice, or just wondered what happens as we die? What exactly does “end of life” refer to? End of life is a broad term, and its meaning can vary from person to person. End of life is a time when death is approaching, usually in a matter of days.

This occurs in various patients experiencing a variety of ailments including end stage cancer, dementia, chronic diseases, and someone who may have organ failure after an accident (3). 

Oftentimes, caregivers have little to no experience in caring for a patient experiencing the end-of-life process and can easily find themselves feeling overwhelmed, confused, and burned out. Understanding what to expect during the final weeks and days of life is imperative to cope with the changes as they occur.

These changes can vary from person to person. Although patients progress through the end-of-life process differently, there is usually a recognizable pattern of decline that occurs. To provide the best possible care and prepare both the dying patient and their family members, it is important for the nurse and caregiver to be able to distinguish the phases of the end-of-life process: transitioning, actively dying, and final moments. 

Transitioning

The transitioning phase, otherwise identified as the pre-active phase, usually signals that a person is approaching the last two-to-three weeks of their life. During this time, caregivers might start to notice obvious changes, an increase in sleeping, for example. A transitioning person can sleep upwards of twenty hours per day. This significant increase is part of an overarching decrease in the patient engaging with the world and day-to-day life.  

Beyond sleeping, examples of this disengagement include interacting less with friends and family, less desire to do one’s usual activities, and a lack of interest in things that were once pleasurable. Additional signs of a patient transitioning include increased weakness and decreased mobility.  

These changes typically include a decline in function, becoming non-ambulatory, chairbound, and ultimately, bedbound. Patients may begin to fall during this time. Progressively, the patient will become more dependent on their caregivers to assist them with activities of daily living (ADL), which include bathing, eating, transferring, toileting, and continence. They will likely become bedbound. 

Another indicator that someone may be transitioning is a change in nutrition and intake. Eating and drinking less is an expected part of decline during this time. Many patients will report a lack of appetite, taste changes, and an overall lack of interest in food and liquids. Changes in swallowing may further complicate a person’s ability to eat and drink. 

It is not uncommon to downgrade a person’s diet during the transition phase. This might include going from a regular diet, down to soft, and finally, to pureed. Liquids are usually given in small amounts and with an added thickener. These changes are necessary to prevent choking and aspiration. Fluid overload is a risk at this point and can detract from one’s comfort, cause swelling, or crackles in the lungs. 

“Approximately 43% of all palliative patients are affected by terminal agitation, which can manifest as restlessness, sweating and patients’ statements as verbal or facial expressions and defensive reactions” (5).  

Increased agitation, anxiety, and restlessness may also arise during the transitioning phase. Terminal agitation and terminal restlessness are both unique to the last week or so of someone’s life and are often caused by physiological changes that occur during the end-of-life process but can also be a result of medication or emotional changes. Even if the patient had been calm previously, it is important to note that these symptoms may still occur.  

Signs of terminal agitation include an inability to remain still, picking at items in the surrounding environment, and increased confusion. Fortunately, there are medications that can be given at the end of life to promote comfort and stop these symptoms when they arise. Lastly, it is not uncommon for the transitioning patient to have visions of and talk to deceased friends and family – both are normal and could sometimes be interpreted as a welcoming sign from loved ones. 

Active Dying

Following the transition phase, most patients will then enter the final phase of the end-of-life process, the active dying period. This precedes imminent death. It can be hard to determine precisely when this stage begins. This phase usually lasts only two to three days and showcases significant signs of patient decline that differ from the previous phase, including a decrease in alertness and responsiveness.

For example, a patient may go from a semi-comatose state to comatose or obtunded and minimal reaction should be expected (1). Their eyes may be open or shut, and there is little movement in all extremities. This period can be described as a deep sleep. 

Caregivers often describe it as a time of waiting. Cognitive changes, in combination with the previous changes in swallowing, make the intake of food, liquids, and medications unsafe. The patient is at high risk for aspiration. Mouth swabs can be used to hydrate the oral cavity and to do mouth care.

Medications that are liquid or can dissolve under the tongue are safe and can be used to manage symptoms at the end of life. Hospice patients are provided a comfort kit of medications to use should symptoms arise.  

Additionally, changes in vitals are expected during this phase, and they typically do not cause the patient any discomfort. For example, temperature fluctuation is common at the end of life. It is not abnormal to have an elevated temperature during the active dying phase. This can be remedied with cooling measures such as a cool towel on the forehead or a fan to cool down the room. The skin may feel clammy as well.  

Following, changes in blood pressure and heart rate may also occur. Blood pressure begins to trend lower during the pre-active phase and can become very low during the last few days of life. The heart rate will usually trend upward and can be well over 100 beats per minute, however, this is just something for the hospice nurse to note and is not usually treated.  

Symptom management at the end of life can be difficult. Failure to adequately control symptoms can have a negative impact on one’s quality of life. These symptoms may include pain, respiratory distress, GI issues, and mobility changes (2).  Pain while dying is one of the most common areas of concern for someone who is actively dying, and of course, no one wants to see their loved one in pain during their final days of life. The body becomes very sensitive to the slightest movement or touch, which can present challenges for caregivers when considering that the patient still needs to be cleaned, changed, and repositioned.  

When the patient is no longer verbalizing their comfort, verbal pain cues must be assessed. These include grimacing, a furrowed brow, frowning, and possibly moaning. In some cases, repositioning can be an effective pain-relieving measure. Thankfully, pain can be treated up until death occurs.

Opioids are commonly used in end-of-life care, due to their ability to effectively manage pain without hastening death. Morphine is an example of a commonly used opioid (4). Nonpharmacological measures can also be used to relieve pain. This may include things like repositioning and soothing music. 

Decreased urination is also common during the active dying phase. This is completely normal and expected. Caregivers may find that they do not need to change diapers as often. Urine may also appear darker in color, appearing a deep amber color due to more concentrated urine. 

Excessive secretions can lead to something commonly known as the “death rattle.” This term is almost synonymous with the last days of life. It can be described as a moist sound that is audible when someone breathes and is a good indicator that death is near. The secretions collect in the throat due to a lack of coughing and the inability to clear them out (8).

Turning the patient on his or her side may help the secretions drain, and there are medications that can be administered to help dry them out. It is important to note that not everyone will experience this, and by the time it occurs, there is a disconnect within the patient, and he or she is not likely to experience any discomfort. 

Maintaining skin integrity and preventing pressure injuries is also an important consideration during this time. With all the other previously mentioned changes occurring, it can be hard to provide the attention that the skin requires. Like other organs, the skin begins to fail in an actively dying patient (9).

This does not necessarily mean that pressure injuries and skin breakdown are inevitable. It is important to consider goals of care during this time. An aggressive approach to preventing skin breakdown might not be what the patient wants or necessarily needs. Measures for pressure injury prevention might include repositioning, use of pillows for elevation, hygiene, and moisture management. 

Final Moments

It can be hard to imagine the final moments of someone’s life. This is especially true for caregivers and families who have witnessed steady decline throughout both stages of dying. There are likely to be signs that death is possible at any moment. A patient can be expected to be comatose with little to no response when death is imminent. The obtunded patient appears to be in a deep sleep. They are no longer verbally or physically responsive to voice or tactile stimulation.  

In addition to changes in vitals described previously, changes in respiration usually occur. This is typically the most obvious change. Patterns can vary from shallow and fast to deep and slow. Periods of apnea are also normal. Cheyne-stokes breathing may also be present (3). 

 Skin changes are also expected; pallor, cyanosis, and mottling are signs that death is near. The body may begin to feel cool, especially in the hands and feet. Comfort medications can still safely be used up until death occurs. As mentioned before, foods and liquids should not be given at this point. Caregivers should continue to talk to the patient, as their hearing will remain until the end. 

Hospice 

Most people wish to die peacefully at home. Unfortunately, for many, this is not the case. Over 30% of people die in a hospital setting (6). Hospice is a form of palliative care and involves caring for the terminally ill as they begin the end-of-life process. A terminally ill patient has a life expectancy of 6 months or less. This is a comfort focused approach to care. The natural process of dying is accepted and allowed to proceed.  

No life prolonging treatments or procedures are elected.  Choosing a hospice allows both patients and their caregivers to achieve their end-of-life care goals. Hospice care includes an interdisciplinary team composed of nurses, physicians, aides, chaplains, and social workers. It includes symptom management, and emotional and spiritual support. There is also a bereavement team that is available after death. Medicare part A covers hospice services nearly completely. 

Hospice care can be a short or long journey, with many ups and downs. For some, the prognosis might be obvious, but for others, it might be filled with many questions and much uncertainty. The benefits of hospice care are proven and can lead to a peaceful death. “The main care focus for patients is symptom management, which improves the quality of the remainder of their life.  

Palliative care involves not only the patient but also their family members. Other measures are also taken so that the patients can live life comfortably and maintain dignity” (7).  Both caregivers and patients seek to understand what end of life care entails and how to maintain comfort at end of life. Hospice clinicians should spend time providing education on this process to all of those involved. 

Spiritual Considerations at End of Life 

Taking care of the dying should be looked at from a holistic point of view. Addressing the physical needs of someone who is dying while ignoring any spiritual needs would be doing a disservice. Spirituality is considered the meaning of life. It may include religion, beliefs, or family traditions. It can mean different things to different people.  

During end-of-life care, it has been shown to be disrupted in patients. Spiritual needs tend to be greater at the end of life.  It is also frequently overlooked by healthcare professionals (10). Palliative care workers can help address spiritual needs in their patients by showing compassion, humility, and openness.  

Dying patients may be conflicted spiritually due to things like guilt and unresolved issues. When spirituality is addressed appropriately, patients can more positively cope with illness. Caregivers of the dying should be aware of the relationship between a terminal prognosis and unmet spiritual needs.  

Conclusion

Hopefully, this has been an informative piece and a guide on what to expect during end-of-life care. No two people experience death and dying in the same manner, and it can be challenging both physically and emotionally during the end of life. Proper symptom management during this time is crucial in ensuring that one dies comfortably. One should also consider any unmet spiritual needs and how, if unaddressed, could lead to poor patient outcomes.  

Palliative care at the end of life can be a great help for caregivers.   Hospice can be a great resource in managing symptoms and providing support up until death and beyond.  Most people do not have experience in caring for a dying person and need education and assistance throughout the journey. Not everyone who is dying will experience all the symptoms mentioned in this course, and it is important to note that everyone experiences the end-of-life process in their own way and at their own pace. 

Sexual Harassment Prevention

Introduction   

Sexual harassment is a serious issue within the healthcare workplace. One systematic review research study found that sexual harassment rates against female nurses was as high as approximately 43% (5). According to an article published in the American Journal of Critical Care in 2021, recent studies estimate around 60% of female nurses and 30% of male nurses have reported sexual harassment (3).  

For both student and registered nurses, patients were the most likely perpetrators. However, this varies, and some research suggests that physicians and patient relatives were also at an increased likelihood of being perpetrators of sexual harassment toward registered nurses (8). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. 

The impacts of sexual harassment affect nurses in many negative ways. There are obvious psychological consequences, but there is also evidence to suggest that work performance and productivity can also be negatively affected (12). Many states have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address sexual harassment. 

What Is Sexual Harassment?

Sexual harassment is commonly thought to be unwelcome contact. However, sexual harassment takes many forms. It can be defined as unwelcome sexual behaviors or actions which may be verbal, physical, mental, or visual (13). 

Listed below are some common examples of potential sexual harassment: 

• Actual or attempted rape or sexual assault 
• Pressure for sexual favors 
• Deliberate touching, leaning over, or cornering 
• Sexual looks or gestures 
• Letters, telephone calls, personal e-mails, texts, or other materials of a sexual nature 
• Pressure for dates 
• Sexual teasing, jokes, remarks, or questions 
• Referring to an adult as “girl,” “hunk,” “doll.” “babe,” “honey,” or other similar terms 
• Whistling at someone 
• Turning work discussions to sexual topics 
• Asking about sexual fantasies, preferences, or history 
• Sexual comments, innuendos, or sexual stories 
• Sexual comments about a person’s clothing, anatomy, or looks 
• Kissing sounds, howling, and smacking lips 
• Telling lies or spreading rumors about a person’s sex life 
• Neck and/or shoulder massage 
• Touching an employee’s clothing, hair, or body (4, 13) 

The U.S. Equal Employment Opportunity Commission defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.” Sexual harassment can also include offensive remarks about an individual’s gender or sexual orientation. No matter the type or amount of harassment, it can disrupt the workplace and potentially create a hostile work environment (10,11) As you can see, the definition of sexual harassment is broad and can encompass many situations. 

Why Are Nurses Vulnerable to Sexual Harassment?

Nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing surpasses many societal norms regarding physical contact and involves intimate care of patients both physically and emotionally. This role is often exploited by perpetrators – they may take advantage of a nurse’s position and caring demeanor as a means to harass them (8). 

Staff-on-staff harassment is also commonly reported by nurses (8). Nurses are potentially predisposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results. 

Key Points for Sexual Harassment

Sexual misconduct vs. sexual harassment – Sexual misconduct is a type of sexual harassment. Sexual behavior can turn into sexual harassment when the recipient receives the behavior in an unwelcome manner. The term “unwelcome” refers to unsolicited or uninvited behavior and undesirable or offensive behavior (11). 

Females and males can both be victims – Any unwelcome sexual behavior may be considered sexual harassment, regardless of the gender of the perpetrator and recipient. Male-on-male, female-on-female, female-on-male, and male-on-female types of harassment may occur (11). 

Sexual harassment can affect witnesses – Anyone who is affected by the sexually offensive conduct may be a victim. This may include a person witnessing or overhearing sexually-harassing behavior (1). 

It can occur outside the working environment – The “working environment” is not limited to the physical location of work. A “working environment” may be extended to any location where work occurs, such as remote locations, off-site locations, and temporary working locations (1, 11). 

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and virtually. Unwelcome sexual conduct through email, phone calls, texts, social media postings, and other mediums may constitute sexual harassment (6). 

Two Types of Sexual Harassment

1. Quid pro quo – Quid pro quo means “a favor for a favor.” In this sense, it refers to an authority figure (manager or supervisor) requesting a sexual favor in exchange for preferential treatment. This could be in the form of a promotion, raise, preferred assignment, or any other job benefit which they may affect (7).
2. Hostile work environment – Another method by which an individual may coerce sexual favors is through the threat or actuality of a hostile work environment. This refers to creating or threatening to create an intimidating, hostile, or offensive work environment in order to influence sexual favors or behavior (7).

What Should Nurses Do If They Experience Sexual Harassment?

If you feel you have been the victim of unwelcome sexual behavior (sexual harassment) there are avenues available to you for support and to report the behavior. 

• While it may not be an easy thing to do (or even possible), try to make it known that the sexual behavior is unwelcome and unwanted. It is your right to inform the person of your stance and to demand the behavior cease. Though this can be difficult and uncomfortable, it is often the most effective method (2). If you decide to confront the perpetrator, try to remain calm and de-escalate the situation as much as possible.   
• You should be explicit in explaining the behaviors that are unwelcome so that the perpetrator can fully understand his/her actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend, coworker, or supervisor who can accompany you or advise you on the next steps. 
• Another way is to interrupt the harasser to distract them from the situation (2) 
• Next, make sure to document the scenario. Write down all of the details that you can recall; including any witnesses. This can be helpful in the future. 
• Reporting the issue through the appropriate channels is the next step. Oftentimes, this involves speaking with your supervisor and someone in human resources. While discussing the situation, do not make excuses for the perpetrator or try to “shrug it off.” 

How or whether you report sexual harassment is a personal choice, and you are not limited. However, you should strongly consider reporting the incident because it could escalate further in the future. The perpetrator may also be sexually harassing others. Every workplace should be free from sexual harassment and many states have laws protecting nurses against workplace sexual harassment, including harassment received from patients and family members. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints. However, you should not be discouraged from reporting through the appropriate avenues. 

 1. Within your organization.

You may contact your supervisor or human resources representative to report an incident. This is often a more comfortable route for nurses as they may be familiar with these individuals. Your organization should have policies and procedures for handling sexual harassment reports which may include escalation to law enforcement as necessary. This is often the fastest method for reporting. Remember that reporting to your supervisor, ethics officer, or human resources official does not preclude you from reporting to other agencies as appropriate. If you wish to remain anonymous, check with your organization to see if they have a policy that gives you that option. 

2. Law enforcement.

Criminal incidents of sexual harassment may be reported to law enforcement as appropriate. Oftentimes your human resource officer can assist in determining if this is necessary or required by state law. If you ever feel that your physical safety is threatened, do not hesitate to contact law enforcement. 

3. Office of Executive Inspector General (state government employees).

State employees may file a report directly with the OEG. To initiate a report, it is best to contact your ethics officer for guidance. 

4. U.S. Equal Employment Opportunity Commission (EOCC).

Sexual harassment is a violation of section 703 VII. The EOCC is charged with administering this statute and provides another option of relief for those who have experienced sexual harassment. The statute for reporting an offense to the EOCC is 180 days from the date of the incident. Of note, the EOCC may hold employers responsible for taking all steps to create an environment free of sexual harassment and can offer an additional avenue for support. This law may be extended up to 300 days depending in the state laws surrounding sexual harassment (10). 

Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (9). 

Concluding Points

• Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behavior or advances. 
• Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. 
• You have a right per federal and state laws to be free of sexual harassment in the workplace. 
• If you experience sexual harassment, you should tell the harasser to stop and report the incident in one of the various methods listed above. Do not forget to document provide a thorough report of the incident. 
• You have a right to report sexual harassment without retaliation per federal laws. 

Following a DNR: An Ethical Dilemma in Nursing

Introduction   

End-of-life issues are often full of emotion and difficult to deal with for all involved. Do-not-resuscitate (DNR) orders can present many moral and ethical dilemmas in nursing. It takes the entire healthcare team, including the patient and their family, to ensure that all final wishes for the patient are followed. In order to understand this ethical dilemma in nursing, we must first define what ethical dilemmas are and what a DNR order is.

Nursing Ethics/Ethical Dilemma

Ethics are a system of moral principles or rules of conduct recognized by a particular group. However, the American Nurses Association (ANA) has developed its own code of ethics. The ANA Code of Ethics with Interpretive Statements includes nine provisions that direct a nurse’s moral and ethical practice. It reads:

Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care.

Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

An ethical dilemma in nursing arises when decisions are made that go against the ANA Code of Ethics with Interpretive Statements.

It is important to note that the nurse's main duty is to be an advocate for their patient, meaning that all actions should be in the patient’s best interest. Adhering to this principle will ensure a clear moral path where ethical dilemmas in nursing can be avoided (1).

DNR 

A DNR order is a situation where, should the patient's health deteriorate and progress to cardiac arrest, the healthcare team will not provide cardiopulmonary resuscitation (CPR). The physician usually gives this order after consulting with the patient and family. Should the patient be unable to make decisions about their health, their designated power of attorney (POA) for healthcare decisions will be able to make that determination.

The DNR order is usually reserved for patients who are gravely or terminally ill and have a strong possibility of dying during their stay at the hospital. Once the DNR is ordered, it will stay in effect until the patient passes, leaves the hospital, or rescinds the order (3, 5).

Possible Ethical Dilemmas with a DNR

There are different situations where a DNR order could pose an ethical dilemma for the nurse. All of these examples involve the nurse's feelings, beliefs, or morals contrasting against the DNR order or the circumstances leading to the DNR order.

• Operating Room/Procedural Suite: In many facilities and healthcare systems, when a patient is undergoing surgical intervention, the DNR is suspended while the patient is in the surgical suite. The consent form for the procedure will indicate that the DNR order will be suspended, and the patient/family must agree to this to proceed with the operation.
  • Should something happen during the procedure/operation, is it right to suspend the patient's DNR wishes? The hospital has metrics, including operating room mortality, that they must keep low. Suspending the DNR gives the facility a better opportunity to meet these metrics. These metric results can be viewed and compared from hospital to hospital.
  • Further, a DNR order can create confusion among the surgical team. Each member may have a different idea of precisely what the DNR means. Some team members may not even believe surgery should occur, given that the patient has a DNR order. In particular, the anesthesiologist may face an ethical dilemma when providing anesthesia to a patient with a DNR order. The anesthesia can cause cardiopulmonary arrest; if the anesthesia causes such, does treating the anesthesia-induced arrest go against the DNR order (4)?

• Suffering: Another dilemma regarding a DNR order is the idea of patient suffering. It is tough to quantify and qualify suffering. That being said, one of the nurse's prime responsibilities regarding their patients is to relieve suffering. No nurse anywhere likes to see their patient in pain and suffering. In their attempts to help reduce that suffering, the nurse may push the patient or the patient's family into considering a DNR order even when it may be inappropriate given the patient's diagnosis and prognosis.
  • This thought could extend to the nurse asking the physician to consult hospice services. It must be clear that not every patient who is suffering should have a DNR order; unfortunately, pain and suffering sometimes go hand-in-hand with recovery.
  • There are also many different types of suffering: physical, emotional, mental, spiritual, etc. Is it right to initiate a DNR order based on these types of suffering alone? Who can say what suffering is, especially when it can't be seen (6)?

• Religion: Another factor that can impact the ethics of a DNR is the religious beliefs of the patient/family as well as the beliefs of the nurse.
  • Some religions do not condone the idea of a DNR. This may stem from an erroneous understanding that the DNR is somehow assisting or facilitating death. This is not the case. A DNR means that no heroic measures will be taken should the patient stop breathing or should their heart stop beating.
  • Yet, the stigma remains. There have also been cases where, when the prognosis was poor and the patient had deteriorated, a DNR was put into place. Later, the family reversed the DNR as they believed a miracle could happen and wanted to give time for their deity to move. Now, the family may be at odds with the healthcare team.  One knows that God can perform a miracle and save the patient, and the other knows that the end is inevitable.
  • The nurse's religious beliefs can also play a part. The nurse may believe that the DNR is premature and that the patient should still fight for life. Maybe the patient is a young one or someone who seems to have much to live for and should not give up. This nurse may find it hard just to let the patient go and could call a Code Blue despite the DNR order (2, 6).

• Capacity: The nurse needs to assess the patient's ability to make decisions for themselves, especially when a patient's faculties may come into question at the end of life. The decision for DNR is not one to be taken lightly; it is a life-or-death decision. The patient must understand what it means to be DNR, how it will affect the care plan, and what it means for their family and loved ones. Allowing the patient to make such a decision based on their condition, though their faculties may be compromised, could become an ethical dilemma (6).

• Effects on treatment: It must be noted that DNR means do not renew, not do not treat. That being said, the perception of the care that should be provided to a patient with a DNR order decreases dramatically. The idea that a DNR patient should have any procedure or operation is often scoffed at. This is especially evident when it comes to procedures meant to provide comfort but also have life-prolonging results.
  • Procedures such as placing a gastrostomy tube to deliver parenteral nutrition may be needed for patient comfort and health but could be perceived as contrary to the DNR order. Also, nurses are far less likely to call a "rapid response" on a DNR patient if their condition begins to deteriorate; the nurse may not even call the physician until the patient passes because the DNR was in place. The patient should be treated as any other patient until the parameters of the DNR order are met. Nurses need to be aware of their own biases regarding DNR. Treatment should not be withheld or altered because of the DNR (2, 5, 6).

How to Avoid Ethical Dilemmas with DNR

All parties agree that the best way to avoid any ethical dilemma regarding a DNR order is to have clear communication. Patients need to communicate their wishes to all their immediate family members. This will keep everyone on the same page and inform them about the patient's desires. Their end-of-life wishes need to be clear and without any confusion. In this way, the patient's wishes can be met despite what the family may believe.

It would be well advised for patients approaching the end of life to appoint a medical power of attorney who will ensure that all their expectations are followed. The decision for a DNR order must also be communicated to the healthcare team. It may not be enough to speak about the desire for the DNR, but also the expectations of their healthcare needs leading up to death as well.

The patient, their family, and the healthcare team must all understand what DNR means when it comes into play and how it will impact their care. Everyone involved in the patient's care must agree with the care plan, including the DNR. The patient and family should be educated about their diagnosis, disease process, prognosis, and treatments. In other words, a decision to have a DNR order must be made in advance.

If nurses are unable to reconcile the DNR decision within themselves even after discussing the issues with the healthcare team, they may need to step away from the situation (5).

Screening for Suicide Risk Factors in Pediatrics

Introduction

Our youth are our future, and their welfare (physical as well as psychological) is a public health concern. In the youth population, suicide is attributed as the 2nd leading cause of death (3). Moreover, suicidal ideations and attempts are even more common than suicidal deaths (3). Our youth's mental health must be addressed when conducting routine or urgent health screenings to deal with this global public health problem. Consequently, screenings for suicide risk factors in pediatrics have proven beneficial in suicide prevention, and most clinical practices have incorporated them into clinical pathways (3). Ultimately, screenings for suicide risk factors are vital tools that can be utilized to detect behaviors relevant to suicide. The results of those tools can serve as guides for warranted intervention. 

The Significance of Screening Tools for Suicide Risk Factors in Pediatrics

The importance of screening tools for suicide risk factors in the pediatric population is evident.  Screening is a fast and efficient method of identifying someone needing further evaluation (6).  Those with positive findings on a suicide risk screening tool should be followed up with an assessment for suicide (6).  

Screening for suicide in the pediatric population is essential. It is also necessary that the tools used are evidence-based for this specific population.  The Ask Suicide Screening Questions (ASQ) is an evidence-based suicide risk screening tool used for medical and behavioral health pediatric patients (5).  This is a frequently used tool that is approved by The Joint Commission (5).  

There is a youth version of the ASQ that is developmentally appropriate for assessing suicide risk in children eight years of age and older (3). More importantly, the ASQ is available in multiple languages. Unfortunately, there are no screening tools for children less than eight years of age; therefore, a full mental health evaluation is conducted (3). Regardless of the approach selected, children are screened without their parents or guardians present for accurate results (3). Additionally, policies or plans of action must be in place if screenings or evaluations indicate positive results (3). 

Suicide Risk Factors in Pediatric Populations

In the past two decades, the suicide rate for adolescents has increased (4).  Males continue to have a higher suicide death rate.  However this rate has doubled for females during this period (4).  The suicide death rate has tripled for those 12-14 years of age (4).  Compared to the adult population, suicidal ideation, self-harm, and suicide attempts are now more common among the younger population (4).  Contributing factors to this increase in suicide are (4). 

• Bullying 
• Social isolation 
• Increase in technology and social media 
• Increase in mental health disorders 
• Economic recession 

Statistics indicate that certain racial and ethnic minority youth experience higher rates of suicidal behaviors. American Indians and Alaska Natives have the highest reported rates of suicide attempts and ideation (4).  There has also been an increase in suicide attempts among the African American youth (4). Risk factors that contribute to this include (4). 

• Access to mental health services 
• Poverty 
• Historical trauma 
• Adverse childhood experiences 

In addition, the prevelance of suicidal thoughts and behaviors has significantly increased among the LGBTQ+ youth (4).  Risk factors unique to this population include(4). 

• Discrimination 
• Violence and trauma 
• Rejection 
• Increased mental health disorders 

While death by suicide is uncommon among children under eight years of age, factors such as anxiety, depression, or suicidal ideation can be present in this age group. (2) Research also indicates that racial disparities in children under 12 exist (2).  Black children are twice as likely to die by suicide than white children (2).  

There are specific warning signs of suicide risk for this age group that include (2). 

• Verbalizing wanting to die or kill oneself. 
• Displaying actions of hurting oneself. 
• Engaging in self-harming behavior. 
• Impulsive aggression. 
• Giving away toys or possessions. 
  

Genetics and history of suicide attempts are other factors to consider. One of the strongest predictors of completed suicides is a previous suicide attempt(4). Even more troubling is that risk significantly increases when there is family history of suicide (4).  

As clinicians, we must maintain accountability for screening and assessing for all indicators of suicide potential. In saying that, environmental factors such as dysfunctional family dynamics, domestic violence, abuse and neglect, bullying, stressors (i.e., life-changing events or losses), and socioeconomic strains should be considered notable suicide risk factors that are highly impactful (4). Also, it is important to inquire about an individual's access to lethal methods, especially if they imply that they have a plan (7).  

The psychological/physical health factors highly linked to suicide include (4,7).  

• Depression or other mental health disorders 
• Traumatic brain injury or concussion 
• Chronic physical condition 
• Alcohol or substance use/abuse 
• Lack of social interaction or support 
• Learning difficulties or disabilities 
• Aggressive or disruptive behavior 
• Excessive video game or internet use (more than five hours daily) 
• In foster care or adopted  
• Sexual orientation 
• Impulsivity  

Signs and Symptoms Associated with Suicide 

There is no doubt that suicide among youth is a serious problem. Often, suicide signs and symptoms are comparable to those noted in depressive situations, and it is a fact that the majority of adolescents and children who attempt suicide do have mental health disorders (8). Most frequently, this is depression (8). 

Some of the signs and symptoms linked to suicidal behavior include (4,7). 

• Isolation from others 
• Hopelessness 
• Ridding self of cherished possessions 
• Discussions of death 
• Irritability or agitation 
• Defiance 
• Expressions of guilt or shame 
• Violent behavior 
• Personality changes 
• Neglecting personal appearance 
• Physical complaints 
• Loss of pleasure in usual activities 
• Low self-esteem 
• Psychosis  
• Changes in eating habits 
• Changes in sleeping habits 
• Feelings of sadness 

Interventions for Concerns Related to Suicide Risk Factors

The ASQ outlines "Next Steps" to take in circumstances of positive results (3). This is based on a "Yes" response to any of the four questions, which would then prompt asking the fifth question. If the answer to question #5 is "Yes," the screening is marked as an acute positive screening, and the patient is considered at imminent risk. In that regard, the patient requires an immediate safety/full mental health evaluation; he/she must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and his/her physician or responsible clinician is notified (3).  

Contrarily, if the answer to question #5 is "No," the screening is noted as a non-acute positive screen that insinuates a potential risk identified. The patient must remain in the clinical setting until his/her safety is evaluated. For that matter, there is a brief suicide safety assessment conducted to establish whether a full mental health evaluation is necessary (3). The clinician responsible for the patient's care or his/her assigned physician is also notified in this case (3). Essentially, the patient's safety is a priority. 

Management of the Suicidal Patient

Assessment and management of a suicidal patient is pertinent to prognosis. Although no intervention is 100% guaranteed to stop an individual from carrying out an act, interventions have proven to be positively impactful in many cases. It has been proven that asking questions pertaining to suicide risk does not increase an individual's likelihood of committing suicide (6). Rest assured that detailed assessments and evaluations facilitate deriving the most appropriate plans of care and should be included in the treatment approach.  

Therefore, the following should be considered when managing suicidal  behavior in pediatric patients (4). 

•  Assess for suicidal risk factors.;  
• Assess mental status.  
• Involve parents or guardians, if possible.  
• Offer psychological education.  
• Consider the need to hospitalize the patient.  
• Interprofessional collaboration or involvement of other services (e.g., psychologist or psychiatrist, counselor, or crisis assessment team/public mental health service).  
• Create a youth safety plan or make a referral to a mental health clinician with this expertise.  
• Focus on treating underlying mental health problems with psychotropic medication (i.e. antidepressants). 
• Psychotherapy.  
• Cognitive Behavior Therapy (CBT). 
• Dialectical Behavior Therapy (DBT). 
• Document the risk assessment, interventions, and patient status. 
• Promotion of continuity of care.  
• Connect to resources. (2). 

As previously mentioned, safety is a priority; hence, safety planning is an important evidence-based treatment approach. Research supports that those who participate in safety planning are less likely to experience suicidal behavior and more likely to seek mental health services (4).  The safety plan consists of a list of coping strategie and sources of support and should encompass the following components (9). 

•  Recognizing signs of patient status worsening.  
• Iidentifying and listing personal coping mechanisms.;  
• Uutilizing family and friends as distractions from suicidal ideations.  
• Iinvolving the family in problem-solving during a crisis.  
• Ccontacting mental health clinicians and restricting access to lethal means.  

Likewise, providing access to a resource such as the National Suicide Prevention Lifeline to patients and families is also a means for them to receive counseling, suicide educational materials, and referrals (1). 

Case Study

A 12-year-old boy is brought to the ED via emergency transport after being found lethargic on the floor of his bathroom with an empty bottle of hydrocodone located close by his hand. It is assumed that he ingested an indefinite amount of hydrocodone tabs. His initial vital signs are temperature, 97.9 F; heart rate, 50 beats/min; blood pressure, 85/57 mm Hg; respiratory rate, 8 breaths/min; and oxygen saturation 95% on room air.  

The patient is difficult to arouse, and Narcan is administered per protocol. Once the patient's condition is stabilized, he voiced his reason for the suicide attempt, which revolved around him being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of his middle school basketball team, which helped him cope until the season recently ended.

Additionally, the patient lives with his grandparents, and he stated, "Everyone is always making fun of how I dress and the car that my granddad drives. I'm just tired of people bothering me, and I wanted it to be all over." This was the patient's first suicidal attempt. During the one-on-one evaluation, it is noted that the patient made minimal eye contact and intermittently placed his head in his hands. You consider the appropriate next steps with the patient's safety of utmost importance. What next steps would you implement for managing this patient's care? 

Recommendations

Conduct suicide assessments and evaluations on every visit because each visit affords the opportunity to identify, educate, and intervene. Research best practices and stay cognizant regarding recommendations for effective approaches associated with suicidal patients. Involve family members, other health care providers, and support personnel for a collaborative approach to meeting the patient's needs. Remember, inquiring about a patient's suicide risk does not increase his/her likelihood of engaging in suicidal behavior but rather serves as a vital means for intervening as opposed to neglecting to address the situation. 

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