Sharing Prescriptions

I am the wellness coordinator at a senior center in an urban area with a diverse population, culturally, educationally, and economically. One day, over coffee, I overhear some of the elders sharing their aches, pains and remedies. I am interested to hear what they have to say because the ladies may share things with each other that they may not necessarily find important to share with me. First, the conversation is quite innocent, and includes mostly the stories about rheumatism preventing them from knitting, and how the weather is going to change because “the knees are acting up again”.  But shortly, sure enough, I hear something quite disturbing to my nursing ears. A 75-year-old Mrs.D., a black sweetheart with grey hair says how she shares her antihypertensive with a neighbor who "has the same symptoms". Time to act, my inner voice whispers, and I gather myself to come up and to interfere this lovely conversation…

Sounds familiar? I believe I heard this story a few times in my life. Once, when my generous grandmother decided to share her blood pressure medication with her neighbor, because she thought that her physician was much smarter and gave her a better drug that would work miracles. I was ten, and thought the world of my grandmother, so instead of telling her that it was not such a good idea to share, I proudly shared the story with my mom (who happens to be a physician) and could not understand why mom looked so petrified when she heard my story. Another time, fifteen or so years later, while doing medication reconciliation with one of my cardiac patients, I discovered that he occasionally takes a Viagra shared by his much younger friend. In both cases, I interfered and explained explicitly that sharing the medications may lead to dangerous outcomes and death. I proceeded to tell my cardiac patient how everybody’s body is different, and that taking a medication that helps one person may kill another. I told him about the blood vessels around the heart (which he already had a very good understanding about), and how they carry oxygen to the heart itself. I then explained that the medication he took could be very harmful because less oxygen got to his heart, and we both agreed that he would immediately inform his cardiologist about his “recreational activity”. These two cases from my personal experience have something in common, yet they are so different from the community settings.

A community nurse by all means should come up to the ladies and explain in easy to understand language, maintaining eye contact and respect that sharing medications may be dangerous. A nurse may emphasize that although she understands the generosity of the client and her good intentions, and mention that there are other, more effective ways to help. She may explain how people, as they get older, take more and more medications, and like mixing blue and yellow paint produces green color, mixing two medications could produce an ugly result. The individual mini-teaching session would increase the knowledge that the elderly have about their own medications, but it would also uncover the need for further intervention.

A community nurse may plan to conduct a teaching session in the senior center. When searching for effective approaches to teaching elderly about the medications, I came across an interesting non-profit Australian publication. (The publication can be found here: http://www.nps.org.au/consumers/publications/medicines_talk/mt19/seniors_talk_the_talk). The publication informs the reader about an unusual approach that can be resorted to, namely seniors teaching seniors about medications. Peer educators conduct interactive sessions, which is an innovative alternative to the general education session held by a nurse. Some seniors may be more inclined to listen to a peer because they associate with them more than with a young nurse.

If a nurse chooses to conduct an education session, she must ensure that the physiological needs of the seniors are met, meaning that the room is well-lit and that the letters on the handouts or overheads are large to accommodate for poor vision; the voice should be relatively loud, low-pitched and the sentences short to accommodate for any hearing deficits that the participants may have. The nurse must carefully review the presentation to ensure the absence of scientific terms, and use a simple language to express the ideas since health literacy may vary among the seniors. The nurse may review the lists of the medications the clients take, and ensure the examples are relevant. The nurse must also allow ample time for the seniors to process the information.

Elderly population strives to remain independent, so they assume a lot of responsibility for self-care. It is important for the community nurses to explore all the opportunities to aid the seniors in acquiring skills to maintain this independence and well-being.

Community as a Potluck Dinner

Sometimes, analogies and metaphors help us understand better how things work, how little pieces and elements come together to form a functioning entity. When I think of a metaphor to explain how community works, I think of a potluck dinner. During a potluck dinner, each one or a group of the participants prepare a dish which is then shared by the members of the potluck as they gather for dinner or lunch. 

I like the metaphor of a potluck dinner for community for several reasons. First, just like the dishes prepared for the potluck reflect the diversity of its members, certain groups in a community reflect the diversity of the population of that community, where cultural diversity is only one of the aspects. Success of the potluck dinner stems from the variety of the dishes made, and from the ability of the dishes to complement each other. Savory Jamaican jerk chicken, spicy Thai salad, crunchy Sauerkraut, hearty baked potatoes, freshly baked bread with olive oil can tell you a lot about the people who prepared them,  about their cultural background and family traditions. Similarly, groups in a community can tell you a lot about its members. For example, taking a walk around Fresh Pond in Cambridge will introduce you to the dog-loving people of the city; a five-minute visit to Aarax store in Watertown will point out a large Armenian heritage presence in town; a brief stop at a playground will give you a general idea about an average town toddlers and theirs moms.

Second, just like no two potlucks are alike, the tables may boast the same dishes, but they are prepared differently, and new dishes are introduced each time; the communities may be similar, but no two communities are exactly the same. The novelty, originality, and constant change of the recipes reflect the dynamic processes that happen in the community. New members move, old timers pass away, new laws are introduced, buildings are erected – all the changes that have an effect on the composition of the community, its health, wellbeing, prosperity, and even diversity. 

Third, the potluck resembles community in the way the members contribute to it: some enjoy cooking and baking and bring elaborate culinary masterpieces, other, less fortunate or prosperous, rely on the rest of the members. Similarly, people with higher income pay more taxes, while disabled and poor rely on the resources that are hopefully available to them. In a good potluck, no one walks away hungry. In a healthy community, no one dies because they did not have a shelter to go to. It is the synergy, or parts working together that produce a functioning unit: just like a helpful lady cleans a coffee spill while another one helps you get a napkin, the fire department puts out a fire while doctors and nurses take care of burn victims. 

The effective community health nurse is aware of cultural differences in the community, an active member that ensures the community’s response to constantly changing environment, introduces innovations, continuously assesses and re-assesses factors that influence health and well-being of the population, informs the members about the availability of the resources.

In the News: Birthright

The routine of work – gym – classes – home does not leave much time for personal enrichment, and I have to make a conscious attempt to spare a minute for reading about current events. I do that not only to be able to carry an intelligent conversations with my Cambridge patients whose IQ, operating vocabulary, and knowledge of current events can intimidate the average population. I push myself to read the news to see how ever-changing world can affect my future as well as my evolving nursing career.

Once in a while, I am lucky to get my hands on an issue of a New Yorker, and if the issue contains an article that has even marginal relevance to healthcare, I consider myself even luckier. A couple of months ago, I read an article about Brooklyn-located Planned Parenthood Center, first birth control clinic in United States, its history that reflected the attitude of society to women’s rights, birth control and abortion. 

A free on-line article can be found here: http://www.newyorker.com/reporting/2011/11/14/111114fa_fact_lepore?currentPage=all

Not surprisingly, the history of the birth control clinic somewhat ran parallel with the history of community nursing. Just like Lillian Wald’s Henry Street Settlement started as entrepreneurial women’s effort to provide the health care for the poor and working class residents of the city, Planned Parenthood launched from a three-employee office that fought a not-so liberal attitude of the population towards a woman’s right to control to give birth. Margaret Sanger, a thirty-seven-year-old nurse and mother was a founder of the clinic. The article talks how Sanger “began nursing poor immigrant women living in tenements on New York’s Lower East Side, and found that they were desperate for information about how to avoid pregnancy”. These “doomed women implored me to reveal the ‘secret’ rich people had”. Over the years, the organization grew at times at the cost of the workers’ own life: some of them had to spend time in jail for distributing contraceptives to the under-privileged population.

I don’t want to ruin the article for you by summarizing every detail. Instead, I highly recommend reading this passionate description of events, which, I am sure, will touch your deeply-rooted empathy and desire to help those in need. The article makes you re-examine your attitude towards abortion, and look at the legislative side of things. I found appalling, how archaic some of the attitudes are, and how low the education on pregnancy prevention subsists. The article mentions how in Idaho, “there is no sex education, except, sometimes, an abstinence program”.

Whether you chose to read the article or not, ask yourself, what you think about a woman’s right to have an abortion.  

What's the Difference Between a Doctor and a Nurse Practitioner?

A lot of heated debate surrounds the issue of NP vs. MD. As expected, nurses support advanced nursing practice, physicians scaffold the alike. Moreover, one encounters stigma of a nurse practitioner being “Oh, is that 'under' a doctor?” But nurse practitioners function as independent health care providers and succeed in the areas where the physicians lack time, training, experience, or desire to practice.

First, non-physician providers (both NPs and PAs) have historically thrived in settings where physicians were unavailable - places they were unable or unwilling to go. For example, UMass Medical School has special incentives for physicians to join practices in the Berkshires, an area remote from any major city. In the same area, NPs open successful practices, where they provide care to a large segment of the population. Nurse practitioners accept positions in university clinics, which most of the physicians decline because they are not lucrative. This is not always the case, and across the country, nurse practitioners and family physicians work together in practices where their skills complement each other.

Second, most NPs focus on disease prevention and health maintenance as well as patient education.  On the other hand, the medical model of healthcare tends to focus on the diagnosis and treatment of disease. The nursing model is more holistic; it incorporates the treatment of the human response to disease and emphasizes the prevention of disease. For example, consider a patient who receives tube feedings at home.  A nurse practitioner is likely to assess patient’s nutritional intake, daily routine and social life limitations due to the presence of a tube, body image, family relationships, identify support systems, and so on in addition to trying to identify pathology.

According to the AANP, more people chose NPs because "they provide individualized care, focusing not only on health problems, but also on the effects health problems have on people and their families; they explain the details of health problems, medications and other topics to help people fully understand how to take care of themselves; and they ask about people's worries and concerns about their health and their health care." Nurses consider caring as a major component of nurse-patient interactions. Nurses are more likely to incorporate empathy and compassion in the care. Nurses are trained to educate patients in the language that patients can easily understand, while physicians are famous for spilling terminology-filled waterfall of information on their patients within a matter of minutes. 

As good as all of the above sounds, an advanced practice nurse may not always meet some of the client needs that a physician does. Nurse practitioners lack the amount of education and training compared to the four years of medical school and three years of residency that the physicians hold.  Due to this fact, nurse practitioner’s scope of practice is narrower than that of a physician. Some believe that nurse practitioners are likely to order more tests and consultations and be quicker to admit patients to the hospital, thereby driving up health care costs. I am not sure if I completely agree with this statement, because a good NP works in collaboration with the physician and seeks advice or approval when ordering additional testing.

For many years, federal and state reimbursement policies limited the care NPs could provide by placing restrictions on the coverage of their services. In 1992, the Balanced Budget Act was passed, which changed the situation. With the BBA in effect, Medicare coverage of nurse practitioner services became liberalized. Medicare once limited coverage to services performed in rural areas and nursing facilities; now nurse practitioners may receive direct Medicare reimbursement regardless of the place of service.

People ask me all the time if I am going to become a doctor or if I wish I became one. I always answer, "No. This is who I am, and I help patients in ways that doctors don't." With the introduction of a Doctorate of Nursing Practice, a nurses is no longer a physician's helper.