Our panel chronic care nurses chats about nurses and chronic care givers on Nursing Notes Live this month. In this episode of the Nursing Notes Live podcast, I got the chance to sit down and chat with our panel of chronic care nurses including Cindy Richards, president of the American Nephrology Nurses’ Association and pediatric renal transplant coordinator at Children’s of Alabama in Birmingham, Ala. and Pam Cacchione, President of the Gerontological Advanced Practice Nurses Association (GAPNA); Endowed Term Chair in gerontological nursing; as well as an associate professor of geropsychiatric nursing at the University of Pennsylvania in Philadelphia, Penn. Here’s that discussion.
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Jamie Davis: Hi, Cindy and Pam, it’s great to have you both here on the show this morning and I’ll start off with my typical initial question for our panelists. Cindy, I’ll start with you. Why don’t you tell us a little bit about why you wanted to become a nurse?
Cindy Richards: I was interested in nursing from the time I was a small child. I was one of those kids that grew up reading all about Clara Barton and Cherry Ames the book series that was written many years ago. It’s just something that always fascinated me. And I guess I’m just one of those people that likes to nurture. I’m driven to help other people. So that was why I went into nursing and I certainly had plenty of opportunity to do that over the last 35 years.
Jamie: Pam, how about you?
Pam Cacchione: Well, I had surgery as a young child. I was probably three years old and ended up having surgery in my hands and interacted with nurses that positively impacted my care and negatively impacted my care. Even at that young age I had recollections of that and I wanted to be able to impact nursing in a positive way and to be able to provide care that speed up recovery as well as manage multiple chronic issues that needed to be addressed at the time of hospitalization.
Jamie: Excellent. Well, we’re going to talk about chronic care nursing and dealing with patients with chronic illnesses. It’s a subject that is near and dear to my heart. I have a daughter with rheumatoid arthritis. Yes, we helped her throughout her life to manage an illness with chronic issues. I’m curious – we’ll start with you, Pam – I know you have experiences with mostly older adults and people may think of older adults as people that are most commonly having chronic illness but what is it that makes it different caring for the chronically-ill patient when compared to that patient with an acute-onset illness?
Pam: So chronic conditions have to be managed over time and need to become a part of the person’s daily routine. With older adults, in particular, the complexity has increased dramatically based on the aging process. It really is a challenge but can be addressed by managing the whole person. One of the things that I think is really critical is setting goals with individuals to help them identify things that they want to reach or accomplishments that they want to achieve so that you can get their buy-in to manage their chronic conditions over time so that they will be able to reach the goals that they would like to reach.
Jamie: Cindy, do you have any thoughts to add to that?
Cindy: Absolutely. I completely agree with Pam. Working with chronic patients regardless of their age group is a lifelong thing. It’s something that occurs over months and many years. You develop a very unique relationship with that patient and any times that patient’s family as well. And you have the opportunity to help them sometimes on a daily basis really make a difference with their life. Trying to help them achieve the goals as Pam said that they’ve set. To help them reach optimal wellness depending on what their condition is, what their chronic illness is. We can have such a huge impact on those patients as nurses. It’s an amazing area to be in and it’s very rewarding. I find that many times I learn as much, if not more, from my patients than I feel like sometimes I’m able to teach them.
Jamie: I feel the same way. How about you, Pam?
Pam: Yes, I totally agree and I want to stress the point of family involvement because this is going to be critical on a day-to-day basis to get by in some of the families and support from those families. Another issue with chronic disease that is really essential with multiple comorbidities as well as just one chronic disease is the issue of recognizing the mental health impact that this will have on an individual and the family and supporting their mental health as well as their physical health along the process so that they’re able to not self-sabotage to the depression and anxiety issues. So it will be critical to again take care of the whole person and their support system, family as well.
Cindy: I completely agree. I have the opportunity in my role where I’m at now, I work primarily with pediatric patients. We have the opposite end of the spectrum that Pam works with, the elderly, and we get to see children from newborns up through late teens even sometimes into their early 20s. And to have such an impact on these kids and helping them to grow, to continue their education, to become the best most independent adult that they can be it’s so rewarding. Like Pam also said, working with these families, especially with a child, you’re not just having the effect of that particular patient. It’s affecting their entire family. Many times their siblings feel left out because mom or dad is having to deal with this chronically ill child or you may have a grandparent or an aunt or an uncle who is the primary caregiver. It’s such a huge impact on the entire family. It’s very rewarding to be able to have an opportunity to make a difference in their lives.
Jamie: I am thinking about both of you being on opposite ends of the spectrum. One of the things that we deal with currently in society is looking at all of the ways we can try to prevent chronic illness from cropping up and that may not be as much of an issue for you, Cindy, with the younger patients. Prevention may not fall into play there as much. With the elderly patients, Pam, prevention is so important to try to keep chronic illness at bay and keep it from coming into onset at all.
Pam: Absolutely. I think that the influence of diet, education, chronic disease the management as far as keeping your illness at a low level as much as possible and keeping up with your primary care visits, that’s in your nursing group is really essential. We do a lot of our chronic disease management in groups here. I work at Living Independently for Elders program at the University of Pennsylvania. So we have 430 elder adults that all have at least four chronic conditions that we are addressing. We have a diabetes group, a hypertension group, or weight loss group to try and promote their health and wellness as much as possible. So it’s a wonderful way to build a community of wellness to be able to do it in a group setting rather than necessarily an individual one-on-one. They get to see that they’re not alone in this whole process of managing their chronic diseases.
Cindy: Absolutely. Pediatrics is much the same except we’re trying to prevent these things from occurring. So a lot of what we do with the children is trying to teach them about how to prevent obesity which will help to hopefully prevent diabetes. Hopefully it will help to prevent hypertension. Hopefully it will help to prevent cardiovascular disease. So we’re on the end where we’re trying to help them not even develop these comorbidities to begin with. I think, Pam and I, we parallel very well in the things that we do and the patients that we work with. It is a challenge. Many times it’s very much a challenge to help them to understand. In pediatrics, we have some camps that my patient population specifically are involved with. And that’s a great way much like what Pam is describing for these kids to realize that they are not the only kid that has scars and they’re not the only kid that has to follow a specific diet or they’re not the only kid that has a a number of medications that they have to take every day to promote their wellness. It’s a great way for them to see they’re not alone and to get that support system from their peers and from many times young adults who have similar conditions that come back and work with them as counselors.
Pam: Absolutely. I think one of the things that’s a little bit different with pediatrics and older adults is we really do allow older adults to make bad decisions. We help facilitate through motivational interviewing better decision making oftentimes but older adults are allowed to make bad decisions within their own lives. Pediatrics is a little bit different but we still allow such autonomy as possible I would think and for older adults it’s a challenge frequently when they recognize that the impacts of their behaviors and their diet and their adherence issues that they – as long as recognize the risks and benefits that they are – we have to allow them that opportunity to make bad decisions in their own care. It could be a real struggle and a real challenge to try and help identify goals that will help them address their health behaviors along the way, to manage their chronic illness.
Cindy: Yes. We deal with a lot of that with the parents who unfortunately sometimes make the bad decisions on behalf of their children. So we see a little bit of that as well in pediatrics – just trying to educate their parents on the choices that the parents are making and how it impacts their children, how it can affect their children in a long term not just today or tomorrow but months and years down the road.
Jamie: You’re really underlining the importance of nurses as educators not just for patients but for their entire support network which you both have addressed in this conversation quite a bit. It’s not just the patient but it is their family and it is their parents, it is their some spouses at home or their children, adult children that are helping to care for them. All of these people figure into the patient’s wellness.
Pam: Absolutely. No doubt about it. As much as you can get them involved. We who are caring for older adults we also have their permission to pull in other family members and ask them. We even communicate with family members to manage, help manage their care. As people age and may or may not develop cognitive issues, we are also dependent on family caregivers which is a remarkable – even probably more in in pediatrics – but the complexity of family caregiving is incredible and so trying to help support families is going to be critical.
Cindy: It’s absolutely is. I agree. Another area that we have to deal with our parents is as the children become teenagers and they’re approaching adulthood is helping the parents learn how to let their children make choices and how to help the parents begin to learn to let go. Letting them become young adults and not hovering over them quite so much, and letting them make some choices and learn how to take care of themselves. So it absolutely takes the whole family whatever support system that these patients have, both on the adult and pediatric side, to help make things work.
Jamie: Pam, what is it about nurses that makes us so good at caring for patients in these chronic situations?
Pam: Well, I think we don’t have a cure mentality. Whereas medicine often has a cure mentality, nurses really have a caring mentality and recognize that there’s the complexity of the situation and we’ll often to the whole person and try and integrate what’s going on in their environment as well as their psycho-social situation and then provide support and expert nursing care and education to improve their health outcome.
Cindy: Absolutely. I completely agree with you, Pam.
Jamie: We talked a lot in the show about helping people make decisions in their career paths as nurse and nursing students or younger nurses, newer nurses to the profession. I am curious what your thoughts are about mentoring and nursing. Cindy, we’ll start with you. How has mentoring figured in to supporting your growth as a nurse and what have you given back as a mentor on the other side?
Cindy: Oh, mentoring is crucial I think to help educate younger nurses, whether they are younger in age are just younger in their career. They need those seasoned nurses to help them with the experiences that they may encounter: things that work, things that don’t work. Just trying to give them positive – being a positive role model for people for other nurses to help them to know that they can make such a difference and have such an impact on their patients. Actually, the association that I’m involved with, we have started a new initiative just started this year. It’s called “Pay it forward” where we’re encouraging members of our association to reach out to either new members or new nephrology nurses. To be in a more traditional mentoring role. Actually, they are to submit some goals. There’s actually a prize for the group or for the payer that has the best goals and the best outcomes from their mentor-mentee relationship over the next year. So mentoring I think is just, it’s absolutely crucial to helping nurses be the best that they can be in their role. My daughter is also a nurse. She just graduated last year and she had some great nurses that she’s working with on her unit. Then she had some not great nurses that she’s worked with. Actually, she got floated to another unit one night and had a nurse who made some very derogatory statements towards the new nurses that were on that unit. It really made an impact on her on how to treat others. I think how we work with each other, how we show the professionalism, how we show kindness to other people is just invaluable to our colleagues in nursing.
Pam: I totally agree. I think one of the things that we as nurses do a better job of is affirming each other. That we all have gifts to bring to the table. We all have expertise to bring to the table and to assist new graduates who come to the profession and identifying their strength and where they need to grow in order to grow from the knowledge to be experts and to show an appreciation for what they bring to the table as well as what you can offer them as a mentor. So it’s going to be critical to identify where the individual is so that you can assist them in their growth as an expert nurse. There is an incredible amount of knowledge that has to be integrated with experience and opportunity within the clinical setting so that you can become that expert. So decisions come more naturally to you and that you can add the caring elements of nursing to the process while you’re caring for individuals in whatever health setting you’re working in. There has to be a synergy that is developed between the mentor and the mentee so that there’s growth on both sides.
Jamie: So, Pam, what advice would you offer to someone that’s thinking – moving from the acute care setting in a hospital, for instance, to caring for patients with chronic disease and illnesses? What advice would you offer to them to be that expert or become that expert in that field?
Pam: I think that getting some acute care experiences is critical because you’ll see people from the community, patients from the community coming in acute care settings struggling with their chronic disease management and you see the end-outcome with their difficulties in the process which will inform how you’re trying to care for someone out in the community with chronic disease management. I think the way the health system is going and healthcare is moving, we are moving to a much more community-based model in trying to prevent hospitalization. One of the things that is really critical and helpful is actually to have an opportunity go on home visits with some of the individuals who are struggling to manage their chronic illness, their chronic diseases because the home visits gives you a much better sense of what the family structure is, family dynamics, potential barriers to them implementing care. It’s an eye-opener to identify how people have to address their daily struggles in their lives, to manage chronic illness and you really don’t get a true sense of that in someone’s primary care setting or even our day center, we don’t get a greater understanding of that until we actually see how they are actually living their lives outside of one who is coming to visit with us. And so that’s a real eye-opener on how to address chronic disease management within their life structure.
Jamie: Cindy, any thoughts to add?
Cindy: Well, I would also just suggest that they try to know as much as they can about whatever the chronic disease processes that that individual patient has. I know when you’re in acute care setting you see a little bit of everything and so it’s a little bit more difficult to hone in on one particular system. I’m nephrology-related. It’s a little harder for someone that’s in the acute care setting to know a great deal about one specific system. But just to know as much as they can about that patient, their chronic illness, their comorbidities and things that they can do when they’re in that acute care setting to try and help them get back to their optimal well-being for when they are discharged from acute-care back into their chronic care setting.
Jamie: It sounds like you both are trying to say that all nurses really need to be chronic care nurses.
Cindy: Yes, I would agree.
Pam: I think that having an element there of health and wellness as well because even with the chronic conditions, there are other elements of wellness that you’re going to want to be promoting in this individual and trying to create a new normal for the individual with chronic condition so that they can create their own life structure around their chronic illness and not let it rule their lives. That they can have a good quality of life despite having a chronic condition or chronic illness. In older adults, we’re dealing with multiple chronic conditions. So we’re really focused on really just quality of their lives and trying to minimize poly-pharmacy and issues around over-treating one condition to be detrimental than others. So we’re about function – how well they are functioning, how well is their cognitive performance working and how are we supporting them to have a good quality of life.
Cindy: Yes, I completely agree.
Jamie: Any final thoughts for student nurses that are moving out of the educational setting into the clinicals or even perhaps as new graduate nurses on things they can do to better prepare themselves because so many of – as we’ve already said, so many of our patients coming in the acute care setting are coming in with perhaps even unrecognized chronic illnesses.
Pam: Well, I would say that one of the important issues is for them to join a professional organization and continue to stay abreast of the current valid evidence-based practice and continue to read and learn and grow. One of the things that I love about healthcare is that it’s constantly changing. We’re learning new things all the time. New medications that are coming on the market, new treatments that are becoming available. Nurses are probably the most trusted profession and we are oftentimes the person that our family and friends come to first to ask about health issues. So we need to stay abreast of our expertise and really kind of to be able to provide a good resource to our family and friends as well as our patients.
Cindy: Yes. The Institute of Medicine did a study back in 2010 and one of the things that they really emphasized is lifelong learning for nurses. And I completely agree. You have to continue that educational process. Whether it’s in a formal setting with going back to get an advanced degree or just going to continuing education conferences so that you can learn more about all of these new things that Pam is mentioning that are coming along. Because the field of nursing – sometimes it doesn’t just change day by day but minute by minute. The field of medicine changes so rapidly and there are always so many new things. I also agree with being part of a professional organization, professional association, whatever your specialty is, be a part of that association because that’s where you can get so much of the education, so much of the mentoring, so much of the networking that’s crucial to make you the best nurse that you can absolutely be. Many years ago I had heard someone speak at a conference about something that was a fairly new technology in dialysis. We had a patient – when I came back about two months later that had something that fit right into that mold and I was able to contact this nurse in Canada and say, “I have a patient that I think needs this therapy. Can you teach me about this?” And she was able to send me information. We actually were able to use it on that patient and make her life better. So that’s networking and that learning is absolutely invaluable to any nurse in practice.
Pam: It’s essential. I think that it’s impossible this day and age to practice nursing without having a collegial group, a networking group, an educational group that you can interact with on a regular basis too and enhance the way you practice nursing. Gerontological nursing is just as relevant as Pediatrics or Med-Surg.
Make sure you check out the entire June 2015 issue of Nursing Notes where we take a look at how nurses help patients manage chronic illnesses. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I sit down with our Get to Know nurse James Fain, associate dean for academic affairs at the Graduate School of Nursing at the University of Massachusetts Medical School in Worcester, Mass. Fain is also editor-in-chief of The Diabetes Educator. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes!