Course

Michigan Renewal Bundle – Part 3

Course Highlights


  • In this course we will learn about the various communication types, threads, and barriers you will encounter during daily practice.
  • You’ll also learn the basics of critical thinking education, followed by common exercises
  • You’ll leave this course with a broader understanding of how to better apply nursing ethics into your daily practice.

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Contact Hours Awarded: 7

Course By:
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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

Nursing can be highly stressful, demanding, and unpredictable. In some cases, nurses are exposed to potential physical, psychological, and mental hazards for upwards of 12-16 hours a day. Each person reacts and responds to extreme stress and trauma in various ways, and because there are so many variables to consider, it has been challenging to diagnose PTSD in nursing 

It is natural for individuals to experience fear, heightened senses, and avoidance after experiencing a traumatic event. Nurses are aware of our body’s natural defense to danger or fear, commonly identified as the "fight or flight" response. There are many scenarios that define a traumatic event, and not everyone identifies them the same. For example, some may say losing a loved one is traumatic for them, whereas others may define life-threatening situations or witnessing one as being traumatic for them – all of which are valid.  

The question now stands, “when do these traumatic events turn into PTSD?  

In order to fully answer this, we must first define PTSD.  

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 

Laura is a 26-year-old nurse of five years who has decided to take a travel nursing assignment to help with the overwhelming demand to care for COVID-19 patients. She is given a wonderful opportunity to make a difference. The staffing agency offered Laura a critical care staff nurse position, where she is expected to care for two patients and work 36 hours weekly on night shift for 13 weeks. Her pay would be $5,000 per week plus a non-taxed stipend for lodging and meals.  

She accepts the assignment and immediately takes leave from her full-time position in Tennessee. She packs her belongings, says goodbye to her family, and begins her venture to California.  

Upon her arrival to the hospital, Laura reports to the critical care department to meet with the nurse manager. Following, she is told by her superior that her contracted assignment has changed and that she will now be taking care of at least seven COVID-19 patients due to short-staffing. Laura is confused and feels as though she cannot say no due to her being under contract, so she attempts to reach out to her agency; no one is available to take her call. She leaves a message in hopes that someone will get back to her as soon as possible, however, she is expected to start her first shift that same evening.  

Laura's first night is horrific; she is caring for seven COVID-19 patients that are all on ventilators, and she has no resources available to her if she has any questions. The environment is overwhelming; patients are lined against the wall, people are crying, a code blue is being 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 or piled into a single room.  

After only three shifts, Laura decides she cannot fulfill this contract because she has no support, is experiencing nightmares, feels extremely agitated, anxious, and seems to be crying all the time. As a result, she reaches out to her agency and informs them of her decision to end the contract. 

The agency tells her that she will be reported to both the Tennessee (her home state) and California Board of Nursing for job abandonment, meaning she cannot practice if she breaks her contract.  

Upon receiving this ultimatum, Laura decides to stay to fulfill the contract.  

Over the next few weeks, Laura notices that some of her co-workers are manifesting a change in behavior. They have become increasingly sad, detached from others, displaying anger toward other staff members, and anxious. Laura feels as though her work environment is toxic, and she wishes she were anywhere else in the world but there, however, she cannot leave. 

This is a prime example of PTSD in nurses.  

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

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you experienced perceived trauma that can be categorized as PTSD in nurses? 

  2. Can a person experience PTSD without having a clinical diagnosis?

  3. When you are having a stressful day, what do you think your colleagues are feeling or thinking? 

  4. How are Laura's colleagues relating to her actions? 

Sign and Symptoms of PTSD in Nurses 

There are many signs and symptoms of PTSD in nurses. 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. Many of the 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 include: 

  • Recurrent distressing memories of the traumatic event 
  • Flashbacks 
  • Nightmares 
  • Severe emotional distress 
  • A physical reaction to something that reminds the person of the traumatic event 

Avoidance: includes any memories, thoughts, or feelings related to the traumatic event on a continuous basis. For examples, see The DSM-5 diagnostic criteria for PTSD include section above.  

Negative changes in mood and thinking includes:

  • Feelings of hopelessness about the future 
  • 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 or drug abuse 
  • Having negative thoughts about yourself, other people, or the world (3)   

Changes in physical and emotional reactions include: 

  • Heightened senses, fight or flight 
  • Insomnia, trouble concentrating 
  • Overwhelming feelings of guilt or shame 
  • Increased irritability, aggressive behavior, outbursts with no provocation 
  • Chronic illnesses, gastrointestinal problems, sweating/shaking 
  • Angina 
  • Self-destructive behavior, depression, hallucinations, anxiety, and feelings of constant sorrow (3)
Quiz Questions

Self Quiz

Ask yourself...

  1. Take a mental moment. Do you feel like you are experiencing any of these symptoms or have experienced them in the past?

  2. As a nurse, can you identify any of these symptoms in your co-workers? Does Laura or her co-workers display any of these symptoms? 

  3. How many times have you brushed off any of these symptoms as just isolated events? 

Types of PTSD 

Since we know that the American Psychiatric Association describes PTSD as a psychological disorder, we know there are different types and severity levels of PTSD. As previously mentioned, everyone can experience the various types, however, we are going to focus on the commonly diagnosed types of PTSD in nurses.  

Overall, there are five types of PTSD, which include: normal stress response, acute stress disorder, uncomplicated PTSD, complex PTSD, and comorbid PTSD (4). 

Normal Stress Response 

The normal stress response, the "fight or flight," is the precursor to PTSD in nurses, and it does not always lead to full-blown PTSD. Any event that causes our natural stress response, such as surgery, an injury or pending thoughts of danger, all initiate 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 a loved one can initiate this early form of PTSD in nurses. While the individual may experience this type of disorder, they will typically overcome the initial stressor. If it becomes prolonged and untreated, it can lead to full-blown PTSD. 

Uncomplicated PTSD 

This type of PTSD in nurses is associated with one major event, making it the easiest form of PTSD to treat. The individual will want to avoid everything that could remind them of the event. 

Complex PTSD 

Complex PTSD is just as the name implies. This type of PTSD in nurses 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 professionals confuse it with a borderline or antisocial personality disorder or dissociative disorders (4). 

Comorbid PTSD 

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

Quiz Questions

Self Quiz

Ask yourself...

  1. Can you identify with any one of the types of PTSD listed?

  2. If any, which type of PTSD might Laura be experiencing? What about her co-workers?

  3. How difficult would it be to recognize the difference between the five types of PTSD within yourself or your co-worker?

Phases of PTSD in Nurses 

There are four phases of PTSD identified by Pyramid Health. The phases are impact (emergency), rescue, intermediate recovery, and long -term reconstruction (5). 

Impact (Emergency) 

The impact phase consists of the initial reaction such as anxiety, helplessness, guilt, shock, or fear. This occurs immediately after the individual experiences the traumatic event. The duration of this phase depends on the severity of the event (5). 

Rescue

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

Intermediate Recovery

The intermediate recovery phase is associated with the individual making the adjustment to return to everyday life. In this phase, the individual can begin to look at other issues within their life. While addressing new issues, they may have the feeling of altruism, in which they feel the love and support from others, causing them to believe that they can also help others. 

Additionally, they may also develop the feeling of disillusionment, in which they feel overwhelmed because they are not receiving the love and support that they think they should, or they realize they are on their own when it ends.

This phase is 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

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

Causes of PTSD 

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

The hippocampus is a component of the brain that works to consolidate information from short- to long-term memory, links these memories to sensations, and enables our ability to navigate through spatial memory (6). The hippocampus is located under the cerebral cortex in the allocortex, and there are two hippocampi, one on each side of the brain that have very distinct roles.  

PTSD is associated with abnormal hippocampal activity (6). It has been noted that PTSD is mainly associated with functional and structural changes in the amygdala, medial prefrontal cortex, and the hippocampus (6). The main role of the posterior hippocampus is in memory retrieval and spatial cognition, whereas the role of the anterior hippocampus is mainly associated with the amygdala, hypothalamic-pituitary-adrenal (HPA) axis, and limbic prefrontal circuitry (6).  

The anterior hippocampal-amygdala connections are thought to underlie atypical memory processes in PTSD, including flashbacks, intrusive thoughts, and nightmares (6). There are current theories of PTSD that identify hippocampal dysfunction as a key contributor to hallmark symptoms of PTSD in nurses(7). 

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 Effect on Nurses 

The COVID-19 outbreak has had a severe impact on the healthcare industry. Professionals are working tirelessly to care for patients who are experiencing health issues caused by COVID-19, leading to a significant spike in PTSD in nurses.  

Professionals in critical care, trauma, and emergency room departments are continuously witnessing death on top of working within a crowded, high-stress environment that often faces short-staffing. 

Factors relating to development of PTSD in nurses: 

  • Age  
  • Work experience  
  • Previous psychiatric history  
  • Marital status  
  • Family support  
  • Coping styles  
Quiz Questions

Self Quiz

Ask yourself...

  1. From the information in the case study, what do you think is causing Laura's symptoms?  

  2. Who do you think would be more susceptible to PTSD, the senior nurse, or the junior nurse?

Prevalence of PTSD in Nurses 

Based on the current U.S. population (223.4 million), around 7 to 10 of every 100 people will have experienced some traumatic event in their lifetime. 20% of the population (44.7 million) suffer from PTSD. The chances of experiencing traumatic events and receiving a PTSD diagnosis within the nursing profession are very high (8).  

In most instances, nurses are trained to put their patients’ needs over their own when they walk in the door. When their shift starts, they attempt to suppress their emotions so they can get through their shift. A nurse may experience a rush of feelings such as anger, guilt, confusion, sadness, sorrow, and grief and sometimes, in extreme cases, 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 from their job. 

A 2009 nursing study covering depression and anxiety revealed a high prevalence of burnout syndrome and PTSD in nurses. The 810-person study revealed that 22% of participants experience symptoms of PTSD, and 18% met the diagnostic criteria for PTSD. Additionally, the results determined that while 86% met the criteria for burnout syndrome, 98% fulfilled the diagnostic criteria for PTSD and were positive for burnout syndrome. The study concluded that nurses with burnout syndrome and PTSD were significantly more likely to have difficulty in their outside life from work (13).  

An additional study that evaluates the results of over 24 publications regarding PTSD in nurses between 1999 and 2019 determined that a majority of nurses with PTSD had the following: 

  • Leadership roles 
  • Negative outlook on patient care 
  • Lack of supportive relationships, staffing, and organizational support 
  • Internalized both short- and long-term patient suffering 

As they continue to push through global pandemics, natural disasters, and continuous tragic events, PTSD in nurses is a prevalent issue that we must address.

Quiz Questions

Self Quiz

Ask yourself...

  1. Would Laura' symptoms or actions lead you to think she was experiencing PTSD? 

  2. What about her co-workers, would their actions lead you to think they were experiencing PTSD? 

  3. Based on the statistics in the section above, does that make a difference on your assessment of Laura's symptoms? 

Current Therapy

PTSD will continue to worsen without treatment. The Veterans Health Administration and Department of Defense (VA/DoD) and the American Psychological Association (APA) in 2017 each established treatment guidelines for PTSD (10). Both guidelines recommend the use of prolong exposure (PE), cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR) therapy (10).  

Non-trauma-focused treatments include medication, relaxation therapy, and stress inoculation training (SIT).

Trauma-focused:

Prolong Exposure (PE)

Prolong exposure (PE) therapy is strongly recommended by both the APA and VA/DoD as a successful treatment of PTSD. PE is based on the emotional processing theory, which stipulates that traumatic events are not emotionally processed at the time of the event. 

PE therapy consists of two main components: in vivo and imaginal exposure (10). 

Cognitive Processing Therapy (CPT) 

CPT utilizes the 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 leads to distorted cognitions regarding themselves, the world, and others. The main goal of CPT is to shift an individual's unhelpful beliefs related to their trauma toward more accommodating, positive and helpful beliefs to promote new learning (10). Sessions usually take 12 weeks, and they incorporate psychoeducation about the cognitive model and exploration of the patient's conceptualization of the traumatic event (10). 

Cognitive Behavioral Therapy (CBT)

Trauma-focused CBT is based on behavioral and cognitive models drawn from cognitive behavior theories, including PE and CPT. This type of therapy includes modifying negative appraisals, correcting the autobiographical memory, and removing the problematic behavior and cognitive strategies. 

It is believed that guilt-associated appraisals tend to evoke negative effects and are usually paired with images or thoughts of the trauma, thus causing a repeated and reconditioned memory of the trauma; Ultimately producing distress, leading to tendencies to suppress or avoid the trauma-related stimuli in individuals (10).  

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 (10). The most important aspect of cognitive restructuring is teaching the patients to identify the various dysfunctional thoughts and erroneous thinking, replace them with rational alternative thoughts, and having them reconsider their beliefs about themselves, the trauma, and the world (10). 

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

EMDR therapy requires healthcare professionals to help a patient move their eyes back and forth while imagining or recalling their traumatic event. This technique allows the individual to reprocess the memory while addressing the past, present, and future aspects of the traumatic memory.  

Non-trauma-focused:

Medication Therapy

The current medication therapy recommended by the APA for PTSD treatment is sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), and venlafaxine (Effexor). Although all medications must be customized for each individual, it is important to note that Zoloft and Paxil are the only FDA-approved medications for the treatment of PTSD (11). 

In some cases, taking antidepressants in conjunction with PTSD medication treatments can serve as beneficial. Those medications include: 

  • Clonidine and Guanfacine, Risperidone for agitation 
  • Clonidine, Prazosin and Trazodone for trauma-related nightmares 
  • Beta-blockers such as Propanol are used to decrease hyperarousal symptoms but it has not been approved by the FDA (12). 
Relaxation Therapy

Relaxation therapy is a form of psychotherapy that utilizes breathing techniques, progressive muscle techniques, and meditation to elicit a voluntary relaxation response of the individual. Sometimes, guided imagery is utilized to have the individual focus on positive images in their mind. This technique helps lower the individual’s blood pressure, relieves tension in their muscles, and lowers their stress. 

Progressive Muscle Relaxation has been utilized to help reduce fatigue and relieve PTSD in nurses. This technique involves sequential tensing of major muscles in the body. This form of relaxation therapy reduces feelings of tension, lowers perceived stress, and can be performed anywhere at any time. This technique has the positive effect of decreasing the pulse rates, increases the individual's oxygen saturation and is sometimes used in conjunction with other forms of psychotherapy (13). 

Stress Inoculation Training (SIT) 

SIT is a form of psychotherapy used for the treatment of PTSD. This training is a type of cognitive-behavioral therapy that teaches the individual coping skills and helps them find new ways to deal with their PTSD symptoms. SIT teaches individuals to react differently in stressful situations and is performed in phases (14).

In the first phase, the individuals learn about their PTSD symptoms, and they identify the traumatic stress that they experienced. Following, the individual learns how to monitor their stress level. In the second phase, they learn new problem-solving strategies and coping skills that help them relax their bodies, control their breathing, interrupt the upsetting thoughts, and help the individual stay in the current moment. Research shows that SIT is one of the most effective forms of therapy for PTSD (14). 

Quiz Questions

Self Quiz

Ask yourself...

  1. Which therapy options do you think best suit Laura and her co-workers and why? 

Coping Mechanisms 

It is sometimes difficult for individuals experiencing PTSD to cope with the mountain of symptoms that they may encounter. For nurses experiencing PTSD, it is critical that they seek treatment and develop coping mechanisms. If their symptoms go untreated, their work performance and quality of patient care may decrease. 

Nurses have resources available to help them cope with PTSD. Some workplaces have elicited the help of psychiatrists or psychologists to provide drop-in services at the worksite. Various positive coping mechanisms include 

  • Spiritual guidance in prayer 
  • Having a strong support system to lean on such as a sponsor that the individual can call when feeling overwhelmed 
  • Including their family in the healing process 
  • Performing mindful meditation or yoga  
  • Performing guided imagery to focus on positive thoughts when the stressors resurface 
  • Prescription medication  
  • Peer support at work 
  • Professional counseling 
  • Group therapy
Quiz Questions

Self Quiz

Ask yourself...

  1. Think of your work environment. Do you know what resources are available to you if you experience PTSD? 

  2. How can you help your colleagues cope with the day-to-day pressures of working in a high-stress environment? 

  3. Looking back to the case study, perform a complete assessment of Laura and her work situation and develop a plan of care for her and her co-workers. 

Conclusion 

PTSD can be a very debilitating condition and affects millions of people every year. Nurses are on the front lines serving the public during a health crisis, and we now know that for them to do their jobs effectively, their mental health must be a priority 

Many organizations now offer counseling, time off, peer support, and incentives for nurses to take care of themselves. With proper treatment, we can alleviate or control PTSD in nurses. Our goal for the future is to continue to make the physical, spiritual, and mental health of all health care workers a top priority so that they can continue to provide the best care to patients.  

End of Life Process

Introduction   

Have you ever cared for someone who was dying, known someone who was on hospice, or just wondered what happens as we die? Hospice involves caring for the terminally ill as they begin the end-of-life process and is utilized by healthcare facilities around the country. 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. Both caregivers and patients seek to understand just what the end-of-life process and its care entails. Hospice clinicians should spend time providing education on end-of-life process to those involved in caring for the patient. 

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 of life is imperative in order to cope with the changes as they occur. The end-of-life process 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. In order to provide the best possible care and prepare both the hospice 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 

This phase of the end-of-life process, 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. 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. 

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.  

Increased agitation, anxiety, and restlessness may also arise during the transitioning phase of the end-of-life process. 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. Despite if the patient had lived peacefully and calm in the past, 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. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What would you say to someone you knew was dying?

  2. What do you know about hospice care? 

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 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. 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 phase of the end-of-life process. 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.  

Pain can also be an area 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 discomfort, nonverbal 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.  

Decreased urination is also common during the active phase of the end-of-life process. This is completely normal and expected. Caregivers may find that they do not need to change briefs as often. Urine may also appear darker, similar to 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. Turning the patient on their 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 they will not likely experience any discomfort. 

Quiz Questions

Self Quiz

Ask yourself...

  1. What is a caregiver likely to feel while experiencing these changes? 

  2. What does comfort mean to you? 

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 phases of the end-of-life process. It is the role of the hospice clinician to provide education regarding what to expect during this time. 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. 

In addition to changes in vitals described previously, changes in respirations usually occur. Patterns can vary from shallow and fast to deep and slow. Periods of apnea are also normal. Cheyne-stokes breathing may also be present. 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. 

Quiz Questions

Self Quiz

Ask yourself...

  1. Have you been present when someone died?

  2. How did it make you feel to witness this? 

Conclusion 

Hopefully, this has been an informative piece on what to expect for end-of-life care. Hospice can be a great resource for both the patient and caregiver. 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 own pace. 

Sexual Harassment Prevention

Introduction   

Sexual harassment is a serious issue within the healthcare workplace. In one study, more than 70% of female staff nurses reported having been harassed by male coworkers or male patients (1). In another study, 35% of student nurses reported having experienced sexual harassment in the previous year (2).  

For both student and registered nurses, patients were the most likely perpetrators. However, physicians and male staff members were also at an increased likelihood to be perpetrators of sexual harassment toward registered nurses (2). 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 can also be affected (3). 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 (4). 

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 (5). 

Here is how sexual harassment is defined by a states ethics act, which governs state officials and employees: 

“…Any unwelcome sexual advances, requests for sexual favors, or any conduct of sexual nature when: 

  1. Submission to such conduct is made either explicitly or implicitly a term of condition of an individuals’ employment. 
  2. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual or, 
  3. Such conduct has the purpose of effect of substantially interfering with an individuals’ work performance or creating an intimidating, hostile or offensive working environment. 

For the purposes of this definition, the phrase “working environment” is not limited to a physical location an employee is assigned to perform their duties and does not require an employment relationship (6).”  

As you can see, the definition of sexual harassment is broad and can encompass many situations.

Quiz Questions

Self Quiz

Ask yourself...

  1. Many nurses do not know that the definition of sexual harassment is broad.  Knowing this, are there any situations you would consider sexual harassment, where you previously would not have?

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 (3). 

Staff-on-staff harassment is also commonly reported by nurses (1). Nurses are predisposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results.

Quiz Questions

Self Quiz

Ask yourself...

  1. What workplace environmental factors can lead to nurses experiencing sexual harassment? 

Key Points for Sexual Harassment

Sexual conduct vs. sexual harassment – Sexual behavior turns 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.

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

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 (5).

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 (5).

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.

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 (5).
  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.
Quiz Questions

Self Quiz

Ask yourself...

  1. What would be an example of quid pro quo?  
  2. How is this type of harassment different than hostile work environment? 

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 (7). 
  • You should be explicit in explaining the behaviors which are unwelcome so that the perpetrator can fully understand their actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend or supervisor who can accompany you or advise you on the next steps. 
  • Next, 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 is the next step

How or whether you report the sexual harassment is a personal choice and you are not limited. Many states laws include you as a nurse entitled to a workplace free of sexual harassment. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints.

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.

Law enforcement:

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

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.

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. 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 (8).

Quiz Questions

Self Quiz

Ask yourself...

  1. How would you handle sexual harassment differently knowing your rights and reporting avenues? 
  2. Are there any previous situation you would have handled differently? 

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 behaviors. 
  • Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. 
  • You have a right per federal law 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 the incident and any reporting thoroughly. 
  • 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. 

What is an Ethical Dilemma in Nursing? 

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 (1). 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 (2). 

 

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 any ethical dilemma in nursing can be avoided.   

Quiz Questions

Self Quiz

Ask yourself...

  1. What is an ethical dilemma in nursing? 
  2. Thinking of your own practice, have you ever had to make choices that compromised your personal ethics or breached the ANA code of ethics? 
  3. Can ethical issues be completely avoided? 

DNR 

A DNR is an order written by a physician that is usually given to those who are critically or terminally ill. The order states that in the event of cardiopulmonary arrest, should the patient's heart stop or should they stop breathing, cardiopulmonary resuscitation (CPR) will not be administered. The decision for a DNR order is always discussed with the patient if they are conscious and have the capacity to make informed decisions. Should the patient be incapacitated, their power of attorney (POA), health care agent, or family member may be allowed to make the decision for a DNR. If a patient is known to be gravely ill, they may already have an existing DNR order, or an advanced directive/living will. Once this document is produced for the institution, the order will go into effect. If a DNR order has been put in place by the patient and physician, the family should not have the power to lift the order once the patient deteriorates and can no longer make decisions (3). 

There was a time in the history of healthcare when there were different tiers of a DNR order. For example, there used to be a medication only/chemical code where medication could continue to be administered, but no compressions or artificial respirations could be performed by the healthcare team; in the end, this proved to be a wasted effort as the medication would be circulated and provide no effect. Many institutions have gotten away from the tires of DNR; what I mean by this is, either there is a DNR order in place for a patient, or there is not. 

Quiz Questions

Self Quiz

Ask yourself...

  1.  Have you ever initiated a DNR order? 
  2. Have you ever been in a situation where a patient's family or healthcare team did not agree with the DNR? 
  3. What is a DNR order? 

Ethical Dilemma in Nursing: DNR 

If a DNR order is put in place by the physician in conjunction with the patient, how could there possibly be any ethical dilemmas in nursing? There should be no problems associated with a DNR order; however, ethical dilemmas arise when the team (patient, physician, healthcare workers, and family) are not all on the same page regarding the DNR. One of the main problems is that different healthcare workers have different interpretations of what a DNR means. It must be understood that a DNR means “do not resuscitate,” and does not mean “do not treat.” To better explore the ethical dilemmas in nursing associated with a DNR order, we will look at scenarios that I have come across over my 25 years of nursing: 

Scenario 1 

A patient is sent from a telemetry unit to radiology for a CT scan. The patient has severe cardiomyopathy and requests a DNR upon admission. The order is noted on the patient’s chart. When they are sent to radiology for the scan, the floor nurse neglects to place the code status on the patient hand-off form. During the scan, the patient becomes unresponsive, and a code blue is called; CPR is initiated, and the patient is intubated.   

During the resuscitation, it is discovered that the patient has a DNR order. The physician running the code continues with CPR, rationalizing that they could ‘not just stop’ the life-saving measures that they had already begun. The patient is revived and transferred to the ICU. Later, during the admission, the family withdraws life support, and the patient expires.  

In this first scenario, we can see that a communication error led to the DNR order not being followed. Once discovered, the physician in charge refused to comply with the order.  Ultimately, the patient passed after a few days on life support.   

This ethical dilemma came to play once the code team realized that the patient had a DNR. The code could have been stopped at this point, and the lead physician could have spoken with the patient's family to explain what had occurred. Many facilities do have policies in place where if a patient goes for a procedure/surgery, the DNR order may be on hold during the time that they are in the procedure; this does not generally include diagnostic scans.   

Scenario 2

A G-tube is ordered for a terminally ill cancer patient. The patient is unable to eat and needs a G-tube for nutrition and medication administration. When the gastroenterologist comes in to do the consult, they discover that the patient has a DNR order. They refuse to place the G-tube due to the DNR order and claim that the G-tube is a ‘life-saving’ measure. The patient is sent back up to their room without having the G-tube placed. After two days, a second consult is placed, and a different doctor approves and places the G-tube. 

The ethical dilemma in this scenario is that the provider refuses to provide treatment based on a poor understanding of what a DNR really means. Again, DNR does not mean “do not treat.”  There are many procedures that can and should be performed regardless of a patient's code status. Though a G-tube can prolong someone's life, it also serves as a means to keep them comfortable through both nutrition and the administration of needed medications, including analgesics. A G-tube insertion can ultimately assist the patient to die with dignity by allowing them to receive alimentation and medicines. It is not solely the provider's responsibility to decide what measures are heroic and which are not. The entire multidisciplinary healthcare team should be involved in the care of the patient, especially when questions could arise as to if a certain procedure is ethical.   

This scenario led to a peer review of the provider's actions.   

Scenario 3

A patient, along with their healthcare team and family, has decided to enact a DNR order. They have been gravely ill for a long time and want "nature to take its course." After the DNR order was placed, one of their family members arrive from out of town; they do not agree with the DNR order and want it to be revoked. The patient refuses, and the DNR is left in place. The next day, the patient becomes unresponsive while the family member is in the room. They insist that the nurse begin CPR and threatens legal action if the code blue is not started immediately. The nurse becomes intimidated by them, as they do not fully understand the DNR order, and commences the code blue. 

The patient is revived and is transferred to the ICU. They voice their anger to the healthcare team about their wishes not being followed; CPR was not to have been administered. Three days later, they become unresponsive and expired; however, this time CPR was not administered, and the DNR was followed. 

Once again, the ethical issue occurred due to misunderstandings and a lack of knowledge from both the patient’s family and the healthcare team. The family member sought to go against the patient's explicit wishes to cancel the DNR. When they would not, as soon as the patient became unresponsive, they demanded that the staff perform CPR. The nurse should have refused, as the family member was not the legal decision-maker, and the patient's expressed wishes were known prior to them falling unresponsive; instead, the nurse breached the DNR and performed life-saving measures. 

Quiz Questions

Self Quiz

Ask yourself...

  1. In your nursing practice, have you ever come across an ethical issue involving a DNR order? 
  2. In the three scenarios, what was the cause of the ethical issues? 
  3. Could these ethical issues have been avoided? 

Conclusion 

A DNR order is put in place when a patient does not want life-saving measures to be performed. The healthcare team and family are involved in the decision-making process, but the decision ultimately belongs to the patient. A patient with a DNR order still needs to be treated for their medical problems and, like any other patient, needs to be treated with dignity and respect. It is important that the healthcare team understands what the DNR encompasses and who can make decisions for the patient should they deteriorate. The nurse must always do what is best for the patient and follow the ANA Code of Ethics with Interpretive Statements. 

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 

As previously emphasized, screening tools for suicide risk factors in pediatrics are vital when assessing the potential for suicidal intentions or behavior (5). These tools are significant because incorporating them into routine assessments can assist in prompt identification and intervention. However, it is warranted that screening tools only account for a portion of the overall assessment pertaining to the risk of suicide in the youth population; thus, those tools must not be solely relied upon (5). 

One of the most popular screening tools for suicide risk factors in the pediatric population is the Ask Suicide-Screening Questions (ASQ) Toolkit (3). The ASQ is a free toolkit approved by the Joint Commission, and it has been validated for use in all populations receiving treatment in medical settings (3). Particularly, 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). 

Quiz Questions

Self Quiz

Ask yourself...

  1. As a clinician, how can you incorporate screening tools for suicide risk factors into your assessments? 

Suicide Risk Factors in Pediatric Populations 

There are numerous risk factors that contribute to suicidal ideations and attempts. Among those suicide risk factors are age, gender, ethnicity, genetics/history, environmental factors, and psychological/physical health factors (4). Elementary and middle schoolers are 40% more likely to attempt suicide, though the risks of suicide-associated deaths are prominent in adolescents 16 years of age and older (4). Likewise, females are 2-3 times more likely to attempt suicide, whereas males are four times more likely to complete suicide acts (4). Even more so, there are more suicide attempts and completions in American Indian, Alaskan Native, Latina/Latino youths (4).  

However, genetics and history of suicide attempts are other factors to consider. One of the strongest predictors of completed suicides with 25-50% of youth victims correlates to previous attempts (4). Even more troubling is that risk significantly increases by at least three times when there is a family history of suicide (4). Those risk factors should not be overlooked.  

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 (4).  

Here are psychological/physical health factors highly linked to suicide (4) 

  • depression or other mental illness 
  • 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  
Quiz Questions

Self Quiz

Ask yourself...

  1. What are some risk factors that indicate immediate interprofessional collaboration? 

  2. How can you, as a clinician, better assess for suicide risks and identify patients who need prompt interventions? 

Signs & Symptoms of Associated with Suicide 

Oftentimes, suicide signs and symptoms are comparable to those noted in depressive situations.  

Some of the signs and symptoms linked to suicidal behavior include (4): 

  • 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  
Quiz Questions

Self Quiz

Ask yourself...

  1. What signs and symptoms would indicate immediate intervention, even without initially using a screening tool? 

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; they must remain supervised in the clinical setting until safety is evaluated. At the same time, the environment is freed of harmful objects, and their 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 their 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 their assigned physician is also notified in this case (3). Essentially, the patient's safety is a priority. 

Quiz Questions

Self Quiz

Ask yourself...

Think about your current practice. 

  1. Are there guidelines in place for dealing with patients who are suicidal?
  2. How often are those guidelines or policies reviewed to assure appropriate practices are being implemented? 

Management of the Suicidal Patient 

Assessment and management of a suicidal patient are 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 (2). Rest assured that detailed assessments and evaluations facilitate deriving the most appropriate plans of care. Therefore, the following ten steps are recommended when assessing for suicide risk in pediatric patients and managing patients who are suicidal: 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 mediation (i.e. antidepressants) and/or psychotherapy (i.e. cognitive behavior therapy aka CBT); document the risk assessment, interventions, and patient status); and arrange for review (2). 

As previously mentioned, safety is a priority; hence, composing a safety plan is a key component in providing effective and efficient care for the individual. The safety plan should encompass the following components: recognizing signs of patient status worsening; identifying and listing personal coping mechanisms; utilizing family and friends as distractions from suicidal ideations; involving the family in problem-solving during a crisis; contacting mental health clinicians and restricting access to lethal means (2). 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). 

 

Quiz Questions

Self Quiz

Ask yourself...

  1. Are you competent in assessing and intervening when faced with a patient who is at risk for suicide? 

  2. What do you believe is the best approach for making sure patients receive appropriate care and follow-up? 

Case Study

A 12-year-old child is brought to the ED via emergency transport after being found lethargic on the floor of their bathroom with an empty bottle of hydrocodone located close by their hand. It is assumed that they ingested an indefinite amount of hydrocodone tabs. Their 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, they gave their reason for the suicide attempt, which revolved around them being bullied by peers on almost a daily basis for the last couple of months. The patient excels academically and was a member of the middle school basketball team, which helped them cope until the season recently ended. Additionally, the patient lives with their grandparents, and 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 their head in their hands. You consider the appropriate next steps with the patient's safety of utmost importance.

 

Quiz Questions

Self Quiz

Ask yourself...

  1. 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 their likelihood of engaging in suicidal behavior but rather serves as a vital means for intervening as opposed to neglecting to address the situation.

References + Disclaimer

PTSD in Nurses
  1. Torres, F. (2020, August). What is Post-traumatic Stress Disorder. Retrieved February 17, 2021, from https://www.psychiatry.org/ 
  2. DSM-5 Diagnostic Criteria for PTSD Trauma-Informed Care in Behavioral Health Sciences NCBI. (n.d.). Retrieved February 17, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part_ch3box16/ 
  3. Posttraumatic Stress Disorder (PTSD): Patient Health Information. (n.d.). Retrieved February 17, 2021, from https://www.mayoclinic.org/diseases-conditions 
  4. PTSD Examined: The five types of Post-traumatic Stress Disorders. (2020, August 26). Retrieved February 18, 2021, from https://bestdaypsych.com/ptsd-examined-the-five-types-of-post-traumatic-stress-disorder/
  5. What are the stages of PTSD. (2020, July 15). Retrieved February 18, 2021, from https://pyramidfbh.com/what-are-the-stages-of-ptsd/ 
  6. Mallvoire, B. L., Girard, T. A., Patel, R., & Monson, C. M. (2018). Functional connectivity of hippocampal sub regions in PTSD: Relations with symptoms. BMC Psychiatry, 18(129).  https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1716-9
  7. Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications. Psychological Review,117(1), 210-232. https://pubmed.ncbi.nlm.nih.gov/20063969/
  8. Posttraumatic stress disorder in doctors. (2005, February 26). Retrieved February 18, 2021, from https://www.bmj.com/330/7489/s86 
  9. Mealer, M. Burnham, E. L., Goode, C. J., Rothbaum, B. & Moss, M. (2009). The prevalence and impact of posttraumatic stress disorder and burnout syndrome in nurses. Depression and Anxiety, 26(12), 1118-1126. https://doi.org/10.1002/da.20631 
  10. Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in Behavioral Neuroscience, 12(258). Retrieved February 28, 2021, from https://www.frontiersin.org/article/10.338/fnbeh.2018.00258 
  11. Medications for PTSD. (2017, July 31). Retrieved March 01, 2021, from https://www.apa.org/ptsd-guideline/treatment/medications 
  12. Gore, T. A. (2018, November 14). Posttraumatic Stress Disorder Medication. Retrieved March 01, 2021, from https://emedicine.medscape.com/article/288154-medication#3 
  13. Rosinta, U., & Robiana, M. (2019, February). The Effects of Progressive Muscle Relaxation in Reducing Fatigue among Nurses in Mental Hospital. Indian Journal of Public Health Research & Development, 10(2), 289-295. Retrieved March 2, 2021 from https://www.web.b.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jml=09760245&AN=13 
  14. US Department of Veterans Affairs, V. (2014, January 15). Stress Inoculation Therapy (SIT). Retrieved March 02, 2021, from https://www.ptsd.va.gov/apps/decisionaid/resources/PTSDDecisionAidSIT.pdf
Sexual Harassment Prevention
  1. Sexual harassment of female registered nurses in hospitals. M. K. Libbus, K. G. BowmanJ Nurs Adm. 1994 Jun; 24(6): 26–31. 
  2. Sexual harassment of nurses: an occupational hazard? S. J. Finnis, I. Robbins J Clin Nurs. 1994 Mar; 3(2): 87–95. 
  3. Sexual harassment in nursing. Robbins, I, Bender MP, Finnis SJ . Journal of advanced Nursing (1997) 25 (1) 163-9. 
  4. Prevalence of sexual harassment of nurses and nursing students in China: A Meta-analysis of observational Studies. Liang-Nan Z, Qian-Qian Z, Ji-Wen Zhang, Li Lu, Feng-Rong An, Chee H, Gabor S, Fang-Yu, Teris C, Ligang C, Yu-Tao. International Journal of biological Sciences (2019). 15 (4) 749-756. 
  5. 2019 Sexual harassment training. Office of executive inspector general for the agencies of Illinois governor (2019). Retrieved from https://www2.illinois.gov/eec/Documents/ 
  6. Ethics Act, 5 ILCS 430/5-65(b). Illinois state officials and employees ethics acts (2019). Retrieved from Ethics Act, 5 ILCS 430/5-65(b). 
  7. Types of sexual harassment: everything you need to know. https://www.upcounsel.com/types-of-sexual-harassment (2020). 
  8. Code of federal regulations. Title 29- labor. Guidelines on discrimination because of sex. https://www.govinfo.gov/content/pkg/CFR-2016-title29-vol4/xml/CFR-2016-title29-vol4-part1604.xml 
  9. Facts about retaliation (2015). U.S. Equal Employment Opportunity Commission. Retrieved from https://www.eeoc.gov/laws/types/facts-retal.cfm 
  10. RETRACTED What is sexual harassment? Illinois sexual harassment and discrimination helpline (2020). Retrieved from https://www2.illinois.gov/sites/sexualharassment/Pages/Definitions.aspx
Following a DNR: An Ethical Dilemma in Nursing
  1. Ethics. (2021). Retrieved from https://www.dictionary.com/browse/ethics 
  2. ANA. (2021). Retrieved from Ethics and Human Rights: https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/
  3. Dugdale, D. C. (2020, January 12). Do-not-resuscitate order. Retrieved from MedlinePlus: https://medlineplus.gov/ency/patientinstructions/000473.htm
Screening for Suicide Risk Factors in Pediatrics
  1. American Foundation for Suicide Prevention (n.d.) Suicide prevention resources. Retrieved on March 12, 2021 from https://afsp.org/suicide-prevention-resources. 
  2. Gordon, M. & Melvin, G. (2014). Risk assessment an initial management of suicidal adolescents. Australian Family Physician, 43(6), 367-372. Retrieved on March 12, 2021 from https://www.racgp.org.au/afp/2014/june/suicidal-adolescents/. 
  3. National Institute of Mental Health (n.d.). Ask Suicide-Screening Questions (ASQ) Toolkit. Retrieved on February 19, 2021 from https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml. 
  4. Pasold, T. (2018). Suicide Screening in Adolescents. Arkansas Childrens Hospitals Research Foundation. Retrieved on March 12, 2021 from https://www.archildrens.org/-/media/Files/for-healthcare-professionals/pediatric-guidelines/Suicide_Screening_in_Adolescents.pdf. 
  5. Patterson S. (2016). Suicide Risk Screening Tools and the Youth Population. J Child Adolesc Psychiatr Nurs, 29(3):118-26. doi: 10.1111/jcap.12148. Epub 2016 Aug 23. PMID: 27552927. Retrieved on March 12, 2021 from https://pubmed.ncbi.nlm.nih.gov/27552927/.
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