April 2020 American Nurse Journal 47

ANAON THE FRONTLINENEWS FROM THE AMERICAN NURSES ASSOCIATION

n Nurses Month n Healthy food trends n Question of conscience

What older adults want

48 American Nurse Journal Volume 15, Number 4

By Susan Trossman, RN

As the number of people over 65 years old con-tinues to grow in the United States, so too is a movement to provide better age-specific care

and truly focus on what older adults say they want in their lives and in their healthcare experiences. Nurses are among those leading and advocating for these efforts, as well as working to ensure older adults can get the right level of care as their health status and life circumstances change.

According to U.S. Census Bureau data for the year 2020, the number of adults 65 years old and over is projected at 56 million, those 85 and older at about 6.7 million, and those 100-plus at around 92,000. To-tals in each age category are projected to increase at least through 2060.

Beyond the numbers, many older adults are focused on aging in place. They want to remain in their homes or preferred communities.

“Most people can do this, but as they get older, it becomes more and more challenging,” said Valerie Sabol, PhD, GNP, ACNP, ANEF, FAANP, FAAN, immediate past president of the Gerontological Advanced Practice Nurses Asso-ciation (GAPNA). “Can they adapt to age-related changes? Do they have family members and friends who can be their caregivers, or do they have to re-ly on paid assistants, which can get very expensive?”

Meanwhile, long-term care facilities requiring skilled nursing continue to close around the country. Of those remaining, the number of beds for Medicaid-eligible residents are limited, often requiring long wait times, and private-pay beds are expensive, said Tracie Harrison, PhD, RN, FAAN, FGSA, a professor at The University of Texas at Austin School of Nursing and director of the Center for Excellence in Aging Services and Long Term Care. Independent living, physical rehabilitation, and post-acute facilities, how-ever, are among those that are expanding.

Senior housing specialists also see the development of more multigenerational, senior co-housing, and other types of active living communities.

Regardless of where older adults live, nurse gerontol-ogy experts say more nurses with specialized knowl-edge are needed to provide care to those 65 and older as they continue to age and contend with more health issues.

In the community

Nurses are key to developing and implementing ef-fective, innovative programs, and one such effort is Community Aging in Place – Advancing Better Living for Elders (CAPABLE), co-created by Sarah Szanton, PhD, ANP, FAAN, professor and director of the Cen-ter for Innovative Care in Aging at Johns Hopkins School of Nursing, and a Maryland Nurses Associa-tion member. The program currently is offered at 27 sites in 15 states and Australia.

CAPABLE is designed to help older adults improve their mobility, functionality, and ability to live inde-pendently, which can reduce hospitalizations and healthcare costs. Older adults who want to partici-pate develop their own action plans and work with a registered nurse, an occupational therapist, and a handyperson to achieve their goals, said Alice Bonner, PhD, RN, director of Strategic Partnerships for CAPABLE.

Bonner describes the 4 to 5 months-long program as focusing on motivational interventions. For exam-ple, a provider may tell a patient that he has to low-er his blood pressure, but that patient may be more concerned about his empty refrigerator at home or his chronic pain.

“Nurses [who are on a CAPABLE team] don’t walk into a home and start talking about medical issues—although they may come up,” said Bonner, an ANA Massachusetts member. “They ask older adults to tell them something about themselves, what they like to do, and what they want to be able to do. It’s an op-portunity to engage in real conversations with peo-ple and support their goals to remain in charge of their lives, live independently safely, and improve the quality of their lives.”

A growing population Nurses advocate for meeting older adults’ needs and wants

ADVOCACY

Valerie Sabol

April 2020 American Nurse Journal 49

For example, if someone’s goal is to be more mobile or cook, nurses and other members of the team work with clients to brainstorm ideas, such as adding an extra banister leading to stairs, using heating pads to reduce pain, and lowering shelves in the kitchen. Along with offering adaptive strategies, nurses also may recommend tools and resources, such as transportation to buy gro-ceries or visit a communi-ty center.

“People want the flexibili-ty, independence, and au-tonomy to live at home,” Bonner said. “They want the familiarity of being near their friends, their faith-based organization, or their barbershop and to engage in community life. And older adults want to contribute—whether it’s volunteering in libraries or schools or participating in intergen-erational programs.”

CAPABLE is aimed at helping people adapt to changes and age in their communities, which Bonner said is “the wave of the future.” She’s currently fo-cused on reaching out to Medicare Advantage plans, health systems, and other organizations to expand the program. Additionally, she sees nurses as having a great role in addressing the needs of older adults in their communities.

Age-friendly acute care

Over the past several years, leaders at Anne Arundel Medical Center (AAMC) in Annapolis, Maryland, have made a concerted effort to provide evidence-based, specialized care to its geriatric population. First, AAMC joined the Nurses Improving Care for Health-system Elders (NICHE) program to strengthen staff expertise as it prepared to open its 30-bed acute care of the elderly (ACE) unit in 2013.

“When you are 45, 65, or 85, your needs and desires are different,” said Lil Banchero, MSN, RN, senior di-rector of the AAMC Institute for Healthy Aging and the ACE unit. The average age of patients on the ACE unit is 85, and they have complex care needs.

To further individualize and en-hance care on the unit, AAMC be-came one of five pioneering orga-nizations to join the Age-Friendly Health Systems Initiative in 2017. At the core of this national and

growing initiative, with 271 recognized participants and 122 exemplars as of January 2020, is the 4Ms Framework for Age-Friendly Care: what matters to patients; ensuring medications don’t interfere with quality of life; addressing mentation-related issues,

including delirium and depression; and promot-ing mobility (see info-graphic, page 50).

Everyone working in the ACE unit must undergo annual NICHE training to stay current on best practices. Nurses are en-couraged to obtain cer-tification in geriatric nursing, according to Banchero.

“We also created a posi-tion called a mobility tech, who focuses on making sure all residents are up and moving every day—and not just going from the bed to the chair,” she said.

Other interventions include:

• Every resident undergoes screening for delirium.

• Patients participate in group “ACErcise” sessionswith a physical therapist to improve their mobilityand strength. This intervention has the added bo-nus of improving mentation and alleviating socialisolation that can occur when someone is hospital-ized. Patients also are encouraged to eat togetherand engage in activities like playing cards.

• Pharmacists check for high-risk medications andpossibly reducing the number of medicationswhen patients are admitted. Pharmacists also re-view medications with patients and their caregiv-ers at the bedside upon discharge. (Some patientshave been admitted with 20 to 30 medications.)

• To encourage and track hydration, often a criticalneed in this population, patients are given easy-to-hold cups with clearly visible lines showingamounts.

Then there are the “my story” white boards in patient rooms that are filled out when patients are admitted and are aimed at getting to the “what matters” com-ponent of the 4Ms framework.

The white board provides personalized information about the patient, such as how they would like to be addressed; favorite sports teams or hobbies; what they don’t like, such as being cold; what they like, such as listening to music; and what their goals are, which may be to go home free of pain. Every nurse also documents what matters most to patients in the Lil Banchero

50 American Nurse Journal Volume 15, Number 4

electronic health re-cord, Banchero said.

“Providing age-friend-ly care requires a par-adigm shift,” she said. “It’s part of our re-sponsibility as health-care professionals to be informative, truth-ful, and plan care that’s safe and mat-ters most to patients.” AAMC continues to focus on rolling out the 4M components organization-wide.

Beyond a one-size-fits-all approach

“People can be similar in age—70 or 80 years old—but their needs and how they feel can run the gamut from vibrant to frail,” said Sabol, also a North Carolina Nurses Association member. “As a healthcare provid-er, you need to be careful to look at the older person as an individual, what they can do, and what matters most to them during every visit or interaction.”

And care must be holistic.

“In nursing, we get so focused on the biological and psycholog-ical aspects of care, that we of-ten forget that we are social be-ings,” said GAPNA President Deborah Dunn, EdD, MSN, GNP-BC, ACNS-BC, GS-C. It’s key that nurses address issues, such as social isolation, especially with the increasing number of “unbe-friended elderly”—those who’ve perhaps never married, had children, or whose fami-ly members or friends are deceased.

Yet another issue that nurses must consider is the shift to home-based care, and the difficulties it may place on family caregivers, according to Dunn.

“The reality is people want to be at home,” Sabol said. “Nurses and other healthcare providers need to be thoughtful about what family caregivers can do and cannot do and provide the education that’s needed long before discharge.”

That said, more nurses are needed throughout long-term care, including post-acute facilities where com-plex care is provided, according to Harrison.

“And one of the biggest challenges is how to provide the best care possible in long-term care if nurses are not invested in this [practice] area,” said Harrison, a Texas Nurses Association member.

Harrison believes building a long-term care work-force includes exposing student nurses to this chal-

lenging specialty earlier in their clini-cal rotations, as well as offering financial incentives and tran-sition-to-practice programs for those willing to work in these facilities. She also believes it’s crit-ical that nurses be-come knowledge-able about policies on aging and advo-cate for changes that benefit this population.

Nurse experts add that the surge in home care servic-es, telehealth, wellness programs, and retail clinics will create even more opportunities and roles for nurses with geriatric knowledge. To that end, they emphasize that nurses must seek out ways to gain that knowl-edge. For example, Dunn noted that GAPNA offers numerous educational resources and advocacy op-portunities for nurses.

Finally, a shared concern among nurse experts is the loss of expertise as more nurses within this specialty retire.

“We must work with our communities to meet the needs of the geriatric population,” Harrison said. “We can’t do it alone.”

— Susan Trossman is a writer-editor at ANA.

Resources

Gerontological Advanced Practice Nurses Asso-ciation: gapna.org

Nurses Improving Care for Healthsystem Elders: nicheprogram.org

Age-Friendly Health Systems Initiative: johnahartford.org/age-friendly-health-systems- initiative

CAPABLE: nursing.jhu.edu/faculty_research/ research/projects/capable

Center for Excellence in Aging Services and Long-Term Care: utlongtermcarenurse.com

ANA Enterprise efforts:

Delirium: Prevent, identify, and treat, a collabora-tion between ANA and the American Delirium Society: nursingworld.org/practice-policy/work-environment/health-safety/delirium

American Nurses Credentialing Center: Certifica-tions: nursingworld.org/our-certifications

Deborah Dunn

Source: Institute for Healthcare Improvement

April 2020 American Nurse Journal 51

HEALTHY NURSE

By Lois Gould, MS, PMP, and Holly Carpenter, BSN, RN

The American Nurses Association (ANA) defines a healthy nurse as one who actively focuses on creating and maintaining a balance and syner-

gy of physical, intellectual, emotional, social, spiritual, financial, personal, and professional well-being. Prop-er nutrition is foundational to being a healthy nurse. Recently, Morrison Healthcare, a division of Compass One Healthcare and a partner of Healthy Nurse, Health NationTM, shared its top five healthy food trends with ANA Enterprise from the 2019 report “Macro food trends in the U.S.”

Ancient grains

You’ll be seeing ancient grains more in grocery stores, prepared foods, and in restaurant offerings, especially as people become more interested in whole and unrefined grains. These super-foods have remained largely unchanged, which introduces cleaner, simpler ingredients to diets. They’re espe-cially beneficial for vegetarians and vegans because they add fiber, omega-3 fatty acids, antioxidants, and plant protein to the menu. Grains such as teff, freekeh, and amaranth are becoming more mainstream as the public’s interest in diverse diets increases.

Healthy snacks

Americans consumed almost 386 billion snacks in 2019, according to the NPD Group Future of Snack-ing Report. As lives get busier, and people become savvier about nutritional choices, the demand for on-the-go, nutrient dense, flavorful snacks is increasing. Embracing the concept that food is medicine, con-sumers recognize their choice of snacks contributes to their daily wellness. You’ll see items like chickpea puffs, mushroom chips, dessert hummus, lotus chips, smoked chocolate, insect protein, and alternative jerky when you reach for your next snack.

Plant-based food

What was once a niche market has now grown into a mainstream industry with sales of $4.5 billion. “Currently, 36% of consumers are eating vegetarian or vegan once a week and 39% of consumers are actively incorporating more plant-based foods,”

according to the Morrison Healthcare report. Plant-based foods support gut health and the immune system, and they reduce inflammation. Soy, once the dominant plant-based protein, is now sharing shelf space with cashew cheese, macadamia butter, al-mond milk ricotta, and seitan sausage. Vegetables like cauliflower and zucchini can now be manipulated into other food forms, such as rice and noodles.

Nonalcoholic beverages

A key area for innovation is nonalcoholic beverages, which impact how people socialize. Bottled waters continue to be one of the fastest growing beverage segments, remaining fashionable with consumers. You’ll find nonalcoholic beverages infused with herbs, spices, and fruits—such as cardamom, berga-mot, dates, lychee, and tamarind—gaining in populari-ty. Low-alcohol and no-alcohol products are readily available. Generally, alcoholic beverages contain calo-ries with little or no nutritional benefit. The Centers for Disease Control and Prevention reports that alco-hol consumption increases your risk for hypertension, some types of cancer, motor vehicle accidents, risky sexual behavior, and violence. Pregnant women and those trying to become pregnant should not drink any alcohol at all.

Sustainability

Sustainability in food encompasses many elements—organic, free-range, biodegradable packaging, locally grown, ethically sourced, non-genetically modified, no inappropriate use of additives such as antimicrobials or hormones, and fair labor practices. “Brands that highlight their impact on the environment are likely to increase their appeal to consumers,” the Morrison Healthcare report states. A great way to focus on sus-tainability is to know where some or all of your food comes from—and with farmers market season gearing up, this only becomes easier. Community gardens, backyard vegetable patches, roadside stands, and well-educated foraging are other possibilities.

— Lois Gould is program manager in the Nursing Practice and Innovation department at ANA. Holly Carpenter is

senior policy advisor in the Nursing Practice and Work Environment department at ANA.

Healthy food trends

References

Olayanju JB. Perspectives on the future of snack-ing. Forbes. October 7, 2019. forbes.com/sites/ juliabolayanju/2019/10/07/perspectives-on-the-future-of-snacking/#2770201e3148

Watrous M. Trend of the year: Plant-based foods. Food Business News. December 27, 2019. food businessnews.net/articles/15105-trend-of-the-year-plant-based-foods

52 American Nurse Journal Volume 15, Number 4

By AJ Cook

Bullying and incivility are all too common in nursing and continue to drive new graduates from the

profession. Although great strides have been made in providing support to new graduates through mentorship, begin-ning from the time a student enters a nursing program all the way to retire-ment, more work must be done to dem-onstrate our code of ethics in our pro-fessional relationships.

Many reports and studies indicate that the problem of bullying and incivility begins before nurses enter the work-force. The National Student Nurses’ Association’s (NSNA) recent study of nursing students and faculty shows that bullying continues to be prevalent in pre-licensure nursing education. The need to foster a cul-ture of respect and demonstrate the values of a role model by upholding ethical behavior should begin from acceptance into a nursing program, according to the re-cent report, “Answer-ing the call to the profession” by Van Der Wege and Keil in the Kansas Nurse.

The American Nurses Association (ANA) Code of Ethics for Nurses with Interpre-tive Statements echoes throughout clinical practice, educational institutions, and within the heart of the NSNA Code of Ethics (Code). NSNA believes in forming professional values from the time students first begin their education. The Code is the core foundational document that provides guidance to students as they develop critical thinking and clin-ical decision-making skills. The first half of the Code focuses on the expectations of nursing students in professional organizations and academic and clinical settings. The second half concentrates on protec-tions for students and helps to create an open learn-ing environment. Together, the ANA and NSNA codes of ethics introduce students to the moral prin-ciples and standards of behavior required of them as future nurse leaders.

Mentorship is a lifelong responsibility based on wis-dom and experience that helps bestow knowledge and confidence among new graduates. As nursing

students graduate and enter the work-force, they rely on the mentorship and support of practicing nurses and nurse managers to help them interpret and im-plement the ANA Code of Ethics into dai-ly practice. Every day we are faced with ethical dilemmas that, if not addressed, persist and intensify. A new graduate needs support to practice with integrity and to learn how to guide patients and families through some difficult decisions. Support from preceptors and nurse lead-ers builds a strong foundation to ensure the retention and resilience of new gradu-ates as they pursue a lifelong career in the most trusted profession. Continuing to challenge our peers to uphold high

standards helps create a future in nursing that is built on moral courage and advocacy.

Nurse leaders are empowered with the ability to not only uphold sound practice but to pass along the professional and personal values required of the pro-

fession. Nurses have an obligation to care for patients and the public and also care for each other. New graduates need an open environment where they are free to learn and ask questions and to grow with mentors who will be there to support them as they begin their journey. Upholding a

strong code of ethics and becoming a mentor for those who follow will continue to strengthen the de-livery of high-quality patient care. Together we can create an environment where we foster the growth and development of new graduates rather than drive them away.

— AJ Cook is president of the National Student Nurses’ Association.

PERSPECTIVE

Incivility and bullying of new graduates Together we can bring about change.

References

Van Der Wege M, Keil S. Answering the call of the nursing profession. Kansas Nurse. 2019;94(2):12-4.

Reinhart RJ. Nurses continue to rate highest in hon-esty, ethics. Gallup. January 6, 2020. news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx

AJ Cook

April 2020 American Nurse Journal 53

Nurses Month: You make a difference

ANA NEWS

As the largest group of healthcare profession-als, nurses make vital contributions to individ-uals, families, and communities around the

world. Given nursing’s immeasurable impact, the ANA Enterprise believes it’s time to expand the tradi-tional National Nurses Week (held annually May 6-12) to a month-long observance.

The Nurses Month theme is “You Make a Difference!” Each week in May will have a different focus:

• Self-care Week—May 1-9

• Recognition Week—May 10-16

• Professional Development Week—May 17-23

• Community Engagement Week—May 24-31

Everyone is encouraged to participate in and pro-mote Nurses Month to recognize nurses and educate the public about the profession’s invaluable work. RNs, hospitals, and other stakeholders can download the Nurses Month toolkit—which includes a Nurses Month logo to use on promotional materials, in social media, and at celebrations and activities—at ana yearofthenurse.org. Be sure to share your Nurses Month activities on social media using the hashtag #ANANursesMonth. Let’s raise the visibility of the nursing profession in 2020! Learn more about Nurses Month at anayearofthenurse.org/about-nurses-month.

Nurses Month webinar—Tell your nursing story

The story of your nursing journey is an essential part of who you are and speaks to your capabilities as a healthcare professional. Learn how to tell it with flair and conviction in the free Nurses Month webinar, “Magnify your voice—Use storytelling to advance nursing,” at 1 pm ET on May 20. Led by award-win-ning filmmaker Carolyn Jones, the webinar will teach you the techniques you need to share your story in a compelling, engaging way that:

• communicates the motivations that led you to become and remain a nurse

• connects the impact and value your nursing

practice has on your patients, colleagues, and community

• shares how you overcome the challenges nurses face every day.

You can use these techniques in a variety of settings to explain your work as a nurse. Register for the webi-nar at anayearofthenurse.org/nurses-month-webinar.

Nurse stories

As we celebrate and elevate nurses during the Year of the Nurse and Midwife in 2020 and Nurses Month in May, we want to highlight nurses through their au-thentic storytelling. Here is a sampling of nurse sto-ries contributed (edited for length) at anayearofthe nurse.org. Join the celebration and share yours.

Alyssa Joye Gogil Vesey, RNMinnesota Organization of Registered Nurses

I am very proud to be a nurse. One of the great attri-butes of the nursing profession is that our diverse opportunities and specializations are interconnected. We can advocate for others and one another no mat-ter which field of expertise we choose. It is fulfilling to help other nurses pursue their dreams.

Devina Horton, MBA, BSN, RNANA-New York

I am glad I chose this diverse career. I have taught as a nursing clinical instructor, worked as a travel nurse, and worked in hospital corporate operations. Nursing offers an array of opportunities and nurses can lead and inspire from any position they hold. Not only do nurses save lives, we also inspire individuals to improve self-care, advocate for patients and loved ones,

and help patients manage chronic diseases and dis-abilities.

Valarie Thomas, DNP, RNAlabama State Nurses Association

I have loved every minute of being a nurse and I nev-er felt like I was going to work. As a nurse educator, I have the best of both worlds. I can teach the next generation of nurses and hopefully lead by example. I can also continue to provide care to patients and families in this role. For the past 3 years, I have trav-eled with a group of students, staff, and professors from various disciplines to Ghana, West Africa, to provide free healthcare clinics annually.

54 American Nurse Journal Volume 15, Number 4

To: Ethics Advisory Board

From: Concerned RN

Subject: Refusal to participate

Two nurses on my unit have submitted written notification stating that they would no longer participate in administering and monitoring

blood transfusions for patients, even in emergency situations, based on their religious beliefs. In our de-partment, being on-call is mandatory and part of the job description. The two nurses have been removed from mandatory call to protect patient safety, since either nurse may be the only nurse available if an emergency did occur. Our hospital’s human resourc-es department is deliberating whether to accommo-date their request.

I believe it’s unethical for a nurse to refuse to care for a patient in an emergency situation and for a nurse to project their beliefs (refusal to participate in the ad-ministration of blood) onto a patient and not honor the patient’s autonomy and desire to be cared for in an emergency. Is my belief supported by the Code of Eth-ics for Nurses with Interpretive Statements (the Code)?

From: ANA Center for Ethics and Human Rights

The Code (nursingworld.org/coe-view-only) justifies the nurse refusing to participate in any “decision or action that is morally objectionable to the nurse.” But there are limitations.

Lachman states that respect for conscience is similar to the ethical principle of the respect for persons, and that conscience-based refusals are based on an individual’s commitment to his or her moral beliefs. The Code is uncompromising in that conscience-based refusals to participate or perform a responsi-bility “exclude personal preference, prejudice, bias,

convenience, or arbitrariness.” Nurses have an obliga-tion to provide for patient safety and a duty to re-spect patient autonomy. Any decision made by the nurse not to participate on the grounds of conscien-tious objection must be explicitly communicated in a timely and appropriate manner. The Code instructs the nurse that “such refusal should be made known as soon as possible in advance and in time for alter-nate arrangements to be made for patient care.”

By entering the nursing profession, the nurse as-sumes a professional obligation to place the well-being and rights of patients at the center of profes-sional practice. According to Stahl and Emanuel, “in emergency situations healthcare professionals must provide medically indicated services despite per-sonal objections.” The Code is clear: Nurses are re-quired to keep their patient safe, to avoid abandon-ing their patient, and to leave their patient only when the nurse is certain that nursing care is available for the patient.

Your unit has decided that the two nurses who refuse to administer blood and monitor a blood transfusion

will not take mandatory call. The unit won’t place these nurses in an emergen-cy where their nonparticipation in this procedure places a patient in harm’s way.

The nurses must understand that their refusal may be one of moral courage, but that this refusal doesn’t protect them from formal or informal consequences. Compromises that protect patient safety and preserve the dignity of all nurses concerned can be difficult to achieve. A safe forum with mutual respect, self-re-flection, and discovery about why the two nurses feel they must refuse to par-ticipate, even in an emergency, may help.

The Code supports the obligation of all nurses to ensure patient safety in every situation.

— Elizabeth Swanson, DNP, MPH, APRN-BC, is a member of the

ANA Center for Ethics and Human Rights Advisory Board.

A question of conscience

ReferencesLachman VD. Conscientious objection in nursing: Definition and criteria for acceptance. Medsurg Nurs. 2014;23(3):196-8.

Stahl RY, Emanuel EJ. Physicians, not conscripts—Conscien-tious objection in health care. N Engl J Med. 2017;376(14): 1380-5.

Do you have a question for the Ethics Inbox? Submit at ethics@ana.org.

FROM THE ETHICS INBOX