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Nursing
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2022 CE for North Carolina nurses

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WHAT’S INSIDE
An Overview of Dietary Supplements for Nurses 1
[3 contact hours] [3 pharmacology hours]
Nurses in many practice settings are likely to encounter patients that are using dietary supplements – some
appropriately – whereas in other instances, not. This course is designed to provide an overview of these products that
will empower nurses to guide their usage safely and effectively. Dietary supplements of many types are widely used by
Americans. As a result, it is likely that nurses, in a variety of settings, will encounter patients who use these products.
Cultural Humility for Healthcare Professionals 15

[3 contact hours]
The purpose of this education program is to present an introduction to cultural humility and offers tools for
healthcare professionals to use when working with diverse patients in a culturally humble manner.
Fundamentals of Telehealth:
Registered Nursing Practice in the Virtual Care Environment 30
[4 contact hours]
This course explores the basic telehealth concepts and technology applicable to the registered nursing telehealth
arena, examining the role of the telehealth nurse, paying attention to legal and regulatory concerns, and temporary
changes to regulations during the COVID-19 pandemic. The course discusses how telehealth can be used in disasters,
emergencies, epidemics, and pandemics and concludes with a review of the competencies for nursing telehealth
practice so nurses can be knowledgeable and effective.
Health Care Management of Patients with Substance Use Disorders 51

[2 contact hours]
Substance use disorder is widespread, varies from culture to culture, and covers a vast array of mind-altering
substances. The purpose of this course is to help health care workers in their treatment of patients with substance
use disorders, also called SUDs, and to provide patients with the tools and interventions to pursue a lifestyle on their
own absent from substance use disorder. The treatment for SUDs includes in- and outpatient programs, a multimodal
treatment approach, possible pharmacological treatments, and behavioral therapy. This course helps to prepare
health care professionals to recognize SUDs, suggest treatments, provide important motivation and encouragement,
and assist with self-management skills that will help with a successful recovery.
Managing Difficult Patients for Healthcare Professionals 65
[5 contact hours]
Healthcare professionals will encounter difficult or hard to manage patients during their career. Examples of
these difficult encounters include workplace violence, non-adherence to medical treatments, and manipulation of
caregivers. This course explores how healthcare professionals can avoid potentially violent situations and work with
difficult patients by being prepared and recognizing the signs and risk factors for these occurrences. De-escalation
skills, diagnosis, preventative measures, training, and planning are all presented in this course to help healthcare
professionals respond to difficult patients and ensure a healthy environment for everyone.
Mindfulness for Healthcare Professionals 87

[3 contact hours]
Building mindfulness-based, stress-reduction principles and techniques into healthcare environments can increase
positivity, safety, and pleasure in work. This course provides healthcare professionals with the knowledge to expand
their understanding of what mindfulness is in its many forms. These include formal, structured approaches as various
approaches to meditation, as well as informal, beneficial daily habits of thinking and behavior. The course explores
the evidence base for the uses and benefits of mindfulness and presents ways to immediately apply these practices
to daily personal and professional life.
Staying Healthy: Vaccine Preventable Diseases 102

[10 contact hours]
The purpose of this course is to provide nurses with information that will enhance their knowledge of vaccine
preventable diseases and how to work with patients and families to reduce the threat of acquiring such diseases.
Course Participant Sheet 146
©2022: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials
presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by
professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC
recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to
ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation
or circumstances and assumes no liability from reliance on these materials.
i
NURSING CONTINUING EDUCATION Book Code: ANCCNC3022C
FREQUENTLY ASKED QUESTIONS
What are the requirements for license renewal?
Licenses Expire Contact Hours Mandatory Subjects
Licenses expire on the last day of the licensee’s 30 (All contact hours allowed
None
birth month every 2 years. through home-study)
How much will it cost?

Course Title Contact Hours Price
An Overview of Dietary Supplements for Nurses 3 $28.95
Cultural Humility for Healthcare Professionals 3 $23.95
undamentals of Telehealth:
F
4 $26.95
Registered Nursing Practice in the Virtual Care Environment
Health Care Management of Patients with Substance Use Disorders 2 $18.95
Managing Difficult Patients for Healthcare Professionals 5 $29.95
Mindfulness for Healthcare Professionals 3 $23.95
Staying Healthy: Vaccine Preventable Diseases 10 $44.95
Best Value - Save $164.70 - All 30 Hours 30 $32.95
How do I complete this course and re you a North Carolina board-

A re my credit hours reported to the
A
receive my certificate of completion? approved provider? North Carolina board?
See the following page for step by Colibri Healthcare, LLC is accredited No. The board performs random
step instructions to complete and as a provider of nursing continuing audits at which time proof of
receive your certificate. professional development by the continuing education must be
American Nurses Credentialing provided.
Center’s Commission on Accreditation.
North Carolina accepts course
providers accredited by ANCC.
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for course completion and certificate Yes! We use SSL encryption, and we Always check your state’s board
issuance? never share your information with website to determine the number of
Please provide your license number on third-parties. We are also rated A+ by hours required for renewal, mandatory
the test sheet to receive course credit. the National Better Business Bureau. subjects (as these are subject to
Your state may require additional change), and the amount that may be
information such as date of birth and/or completed through home-study. Also,
last 4 of Social Security number; please make sure that you notify the board of
provide these, if applicable. any changes of address. It is important
that your most current address is on file.
What if I still have questions? What are your business hours?

No problem, we have several options for you to choose from! Online at EliteLearning.com/Nursing you will see
our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us
at office@elitelearning.com, or call us toll free at 1-866-344-0971, Monday - Friday 9:00 am - 6:00 pm, EST.
Licensing board contact information:

North Carolina Board of Nursing
PO Box 2129 I Raleigh, NC 27602 I Phone (919) 782-3211 I Fax (919) 781-9461
Website: http://www.ncbon.com/
ii
Book Code: ANCCNC3022C NURSING CONTINUING EDUCATION
How to complete continuing education
Please read these instructions before proceeding.
Read and study the enclosed courses and complete the self-assessment exercises. To receive credit for your
courses, you must provide your customer information and complete the mandatory evaluation. We offer four
ways for you to complete. Choose an option below to receive credit and your certificates of completion.
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iii
NURSING CONTINUING EDUCATION Book Code: ANCCNC3022C
An Overview of Dietary Supplements for Nurses
3 Contact Hours
Release Date: January 11, 2021 Expiration Date: January 11, 2024
Faculty
Bradley Gillespie, PharmD, is a clinical pharmacist. He has Content Reviewer: Shellie Hill, DNP, FNP-BC, currently serves
practiced in an industrial setting for the past 25+ years. His as full-time faculty as the FNP program coordinator and assistant
initial role was as a clinical pharmacology and biopharmaceutics professor in the MSN-NP program at Saint Louis University.
reviewer at FDA, followed by 20 years of leading early She has been a practicing family nurse practitioner for 19 years
development programs in the pharma/biotech/nutritional and an RN for 26 years. Most of her clinical practice has been
industries. In addition to his industrial focus, he remains a in primary care. She also has experience in urgent care and
registered pharmacist and enjoys mentoring drug development cardiology. Clinically, she works in corporate health care clinics
scientists and health professionals, leading workshops, and part time and volunteers as an FNP in a clinic that manages
developing continuing education programs for pharmacists, underserved patients.
nurses, and other medical professionals. Shellie Hill has disclosed that she has no significant financial
Bradley Gillespie has disclosed that he has no significant or other conflicts of interest pertaining to this course.
financial or other conflicts of interest pertaining to this
course.
Course overview
Nurses in many practice settings are likely to encounter patients This educational program is designed to provide an overview of
that are using dietary supplements – some appropriately – the following:
whereas in other instances, not. This course is designed to ● The regulation of nutritional supplements.
provide an overview of these products that will empower nurses ● Main categories of nutritional supplements, their potential
to guide their usage safely and effectively. Dietary supplements activity, and safety concerns.
of many types are widely used by Americans. As a result, it is ● Resources available to provide additional information.
likely that nurses, in a variety of settings, will encounter patients
who use these products.
Learning objectives
Upon completion of the course, the learner should be able to do Discuss the difference between macrominerals and
the following: microminerals.
Detail two key events responsible for the regulation of Develop an awareness of “miracle” supplements.
dietary supplements. Identify two body systems that may be susceptible to
Describe one sign associated with vitamin deficiency. adverse events when using St. John’s wort.
Name one benefit of vitamin C that has support in the State one potential drug interaction associated with the use
scientific literature. of St. John’s wort.
Explain why supratherapeutic doses of water-soluble and fat- Provide a potential use for fish oil that is well supported by
soluble vitamins can have different consequences. the scientific literature.
How to receive credit

● Read the entire course online or in print which requires a ● Depending on your state requirements you will be asked to
3-hour commitment of time. complete either:
● Complete the self-assessment quiz questions which are at ○ An affirmation that you have completed the
the end of the course or integrated throughout the course. educational activity.
These questions are NOT GRADED. The correct answer is ○ A mandatory test (a passing score of 70 percent is
shown after you answer the question. If the incorrect answer required). Test questions link content to learning
is selected, the rationale for the correct answer is provided. objectives as a method to enhance individualized
These questions help to affirm what you have learned from learning and material retention.
the course. ● If requested, provide required personal information and
payment information.
● Complete the MANDATORY Course Evaluation.
● Print your Certificate of Completion.
CE Broker reporting
Colibri Healthcare, LLC, provider # 50-4007, reports course Kentucky, Mississippi, New Mexico, North Dakota, South
completion results within 1 business day to CE Broker. If you Carolina, or West Virginia, your successful completion results will
are licensed in Arkansas, District of Columbia, Florida, Georgia, be automatically reported for you.
Accreditations and approvals
Colibri Healthcare, LLC is accredited as a provider of nursing
continuing professional development by the American Nurses
Credentialing Center's Commission on Accreditation.
Page 1 Book Code: ANCCNC3022C EliteLearning.com/Nursing

Individual state nursing approvals
In addition to states that accept courses offered by ANCC Kentucky Board of Nursing, Provider #7-0076 (valid through
accredited providers, Colibri Healthcare, LLC is an approved December 31, 2023). Mississippi Board of Nursing, Provider #50-
provider of continuing education in nursing by: Alabama, 4007; New Mexico Board of Nursing, Provider #50-4007; North
Provider #ABNP1418 (valid through February 5, 2025); Arkansas Dakota Board of Nursing, Provider #50-4007; South Carolina
State Board of Nursing, Provider #50-4007; California Board of Board of Nursing, Provider #50-4007; and West Virginia Board of
Registered Nursing, Provider #CEP17480 (valid through January Registered Nurses, Provider #50-4007. This CE program satisfies
31, 2024); California Board of Vocational Nursing and Psychiatric the Massachusetts States Board’s regulatory requirements
Technicians (LVN Provider # V15058, PT Provider #15020; valid as defined in 244 CMR5.00: Continuing Education. This CE
through December 31, 2023); District of Columbia Board of program satisfies the Massachusetts States Board’s regulatory
Nursing, Provider #50-4007; Florida Board of Nursing, Provider requirements as defined in 244 CMR5.00: Continuing Education.
#50-4007; Georgia Board of Nursing, Provider #50-4007;
Activity director
Lisa Simani, MS, APRN, ACNP, Nurse Planner
Disclosures
Resolution of conflict of interest Sponsorship/commercial support and non-endorsement
In accordance with the ANCC Standards for Commercial Support It is the policy of Colibri Healthcare, LLC not to accept
for continuing education, Colibri Healthcare, LLC implemented commercial support. Furthermore, commercial interests are
mechanisms prior to the planning and implementation of the prohibited from distributing or providing access to this activity to
continuing education activity, to identify and resolve conflicts of learners.
interest for all individuals in a position to control content of the
course activity.
Disclaimer
The information provided in this activity is for continuing to diagnostic and treatment options of a specific patient’s
education purposes only and is not meant to substitute for the medical condition.
independent medical judgment of a healthcare provider relative
©2022: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri
Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics
covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to
provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional
services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in
this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor
circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The
models are intended to be representative and not actual customers.
Course verification
All individuals involved have disclosed that they have no Bill No. 241, every reasonable effort has been made to ensure
significant financial or other conflicts of interest pertaining to this that the content in this course is balanced and unbiased.
course. Likewise, and in compliance with California Assembly
INTRODUCTION
Most Americans consume at least one product defined as Supplements that are commonly consumed contain vitamins,
a dietary supplement each day; others may use them on minerals, herbs, fish oil, and probiotics (NIH, 2020b).
a more irregular basis. Although products categorized as The Federal Food, Drug, and Cosmetic Act defines dietary
dietary supplements can include a variety of preparations, this supplements similarly to the NIH but adds that these substances
educational program will consider common dietary supplements are used to increase total dietary intake. Further, the U.S. Food
identified by the National Institutes of Health’s (NIH) Office of & Drug Administration (FDA) states that dietary supplements
Dietary Supplements as vitamins, minerals, herbs, botanicals, are not intended to treat, diagnose, prevent, or cure diseases.
amino acids, probiotics, and fish oils. Dietary supplements As such, drug-like marketing claims such as “pain reducer” or
can be ingested using a variety of formulations. Examples “treatment of heart disease” are prohibited (FDA, 2020).
include tablets, capsules, powders, drinks, and energy bars.
HISTORY
Contemporary thinking may assume that the nutrient depletion brown rice is modified to become white rice). These efforts
that some Americans suffer as a result of processed food succeeded in extending food longevity but also led to unknown
consumption is a recent problem. Nonetheless, a review of and sometimes harmful consequences (Tweed, 2017).
nutritional history suggests that we have faced this problem For example, well-intentioned grain processing decimated
for over 100 years. In actual fact, today’s most popular dietary critical B vitamins, resulting in an increased incidence of two
supplement, the multivitamin, was developed in the early 1900s. diseases common to the time: pellagra – niacin deficiency
Before inventing this critical supplement, though, scientists first resulting in a variety of sores and sometimes delusions; and
needed to acknowledge and understand the existence and need beriberi – thiamine (vitamin B1) deficiency, which can lead to
for substances now known as vitamins. Before this era nutrients nerve damage, sometimes to the extent of paralysis. Further, the
were roughly categorized into three food groups: proteins, practice of milk sterilization destroyed its vitamin C resulting in
carbohydrates, and fats. Contemporary thinking of the time also an increased incidence of scurvy. Interestingly, scurvy commonly
blamed poor sanitation and hygiene deficiencies as the source of occurred in affluent families, those able to afford the so-called
all disease. In response to this concern, food was often sterilized “best food.” These maladies were quite mysterious and not
to remove germs and toxic substances. Grains were milled to understood (Tweed, 2017).
remove their husks, and rice grains were polished (this is how
EliteLearning.com/Nursing
Book Code: ANCCNC3022C Page 2
The practice of rice polishing resulted in a hotbed of scientific influential advocate for the importance of vitamins. As a result of
interest around the turn of the 20th century. Many scientists in these efforts, in 1929 the award was granted to these two men,
Europe and Asia realized the nutritional value of rice polishing cementing the importance of vitamins (Carpenter, 2020).
(the substance removed from brown rice during its refinement) Over time, as the body of research developed, it became
and endeavored to identify what part of it was important. Some evident that vitamins were critical to supporting growth and
of the more industrious investigators even tried to synthesize this function. It is now established that there are a total of 13
material. One example of such a trailblazer was Casimir Funk, vitamins: vitamins A, C, D, E, K and the B vitamins (thiamine,
a Polish biochemist. In 1910 he reported that he had isolated riboflavin, niacin, pantothenic acid, biotin, B6, B12, and folate).
the active factor in rice polishing. Though history would show Each of these diverse substances has different roles – some
that his findings were faulty, he did go on to make a critical help to avoid infection or promote nerve health; others assist
contribution to the science, suggesting that his isolate belonged in the extraction of energy from food or serve as critical factors
to the chemical class of amines. Further to that, he hypothesized required for proper blood coagulation. Generally, if individuals
that all of the organic trace nutrients linked to preventing disease follow proper dietary guidelines, they can consume the majority
belonged to that same class of chemicals. He then created the of the vitamins that they need from the food that they eat
term “vitamin,” to describe all of these vital amines. In a few (National Institute on Aging [NIA], 2019).
years, Funk’s hypotheses were disproven; not all of the chemicals
in this category were amines. Nevertheless, the nomenclature In addition to vitamins to promote proper function, the body
was slightly shortened to vitamin, and it stuck (Carpenter, 2020). also relies on a number of minerals. Although most minerals,
such as iodine and fluoride, are required in only small quantities,
For at least 14 years before 1926, intermittent nominations had greater quantities of others are needed. Examples of minerals
been submitted for the Nobel Prize in Physiology or Medicine on with larger requirements are calcium, magnesium, and
the basis of vitamins. Although it is unknown why vitamin work potassium. The good news is that, like vitamins, a varied and
never rose to the level of receiving this valued award, it may balanced diet is typically adequate to supply enough of most
have been a result of skeptics who declared these substances to minerals needed to support good health (NIA, 2019).
be only hypothetical; it was true that, up until this time, no one
had ever seen a vitamin. This all changed in 1926 when a pair In summary, Funk’s declaration that vitamins are vital is as true
of Dutch scientists, Jansen and Doanth, produced pure crystals today as it was when he first suggested it over 100 years ago.
extracted from rice polishing. Only one-hundredth of a milligram Without them, horrible things will happen to the body. This well-
of their extract, administered daily, was required to cure vitamin- accepted truth makes it very easy to market and sell vitamins
deficient pigeons. By 1929 the award committee decided that it as well as other substances purported to promote health. This
was time to honor the work of the vitamin pioneers. is evidenced by a current explosion of start-up organizations
stating that their products work for almost everyone. The
The problem was that so many had contributed to this Internet is packed with examples of sometimes expensive
developing science, whose work should be honored. Ultimately, vitamin concoctions claiming to be essential for good living,
the prize was jointly awarded to Christiaan Eijkman and Sir many for seemingly exorbitant prices. Some marketers take
Frederick Hopkins. Eijkman’s work centered around his study it a step further by offering online personal surveys allowing
of beriberi in the Dutch East Indies. He noted that some of the consumers to create personalized supplement blends – in
chickens in his laboratory developed symptoms of beriberi after essence a multivitamin engineered to meet each individual’s
the cook refused to allow the birds to be fed leftover rice. When needs. A wise consumer may acknowledge that, though
rice was procured from an alternative source, the animals quickly vitamins are important and worthwhile, perhaps not all available
recovered, leading him to believe that something in the rice supplement regimens are worth their lofty prices (Palus, 2019).
was responsible for preventing this disorder. Hopkins was an
REGULATION
Even though FDA-regulated products account for over 20% featuring an authorization of FDA to demand solid evidence
of consumer expenditures (Abram, 2017), the agency is not of safety and proper labeling for new drugs, sanctioning
responsible for regulating harmful dietary supplements until a factory inspections, and adding new enforcement tools
tainted or mislabeled product is sold. Further, the agency has (FDA, 2018).
no responsibility for ensuring the effectiveness of supplements. 2. Nutrition Labeling and Education Act of 1990 (NLEA): Although
Nonetheless, FDA is planning to modernize and strengthen the NLEA of 1990 was geared mainly toward food labels,
its oversight of dietary supplements. To this end it has listed a certain aspects of this mandate were relevant to the
number of steps designed to improve the safe and effective use regulation of dietary supplements. The nutritional labeling
of dietary supplements, with a primary goal of preserving access guidelines described in this legislation were designed to
while protecting consumers from dangerous products (Norman, work in tandem with previously established requirements
2019). for statements of identity, net contents, ingredient lists,
In spite of FDA’s intention to modernize the regulation of and the name and place of the manufacturer/distributor. Of
dietary supplements, any useful modifications to law are not yet interest, NLEA regulated health claims that could be made
in place. Organizations manufacturing nutritional and dietary on behalf of a supplement. NLEA provisions were issued in
supplements are well aligned with Congress, which typically January 1993 and applied to all supplements except those
endorses industry-friendly regulations that support the concept that were eligible for exemption. In the case of some small
of self-regulation (Brown, 2019). Nevertheless, hundreds of laws businesses or where labeling was impractical or not feasible,
have been enacted to provide oversight of these diverse product manufacturers could apply for such exemptions (GovTrack,
lines. Over the history of FDA, many significant events have n.d.b.).
been recorded. 3. The Dietary Supplement Health and Education Act of 1994
(DSHEA): DSHEA was unanimously passed by Congress
Seven key events are responsible for the regulation of the dietary based on a number of findings that emphasized the need
supplement industry today. Taken together, these laws effectively to communicate information to the public regarding
provide a working definition of a dietary supplement. the potential risks and benefits of dietary supplements.
1. The 1938 Food, Drug, and Cosmetic Act: In 1938 the Federal DSHEA was intended to protect the rights of consumers
Food, Drug, and Cosmetic (FD&C) Act was passed in to continue to access safe supplements as a means
response to a legally marketed toxic elixir that killed 107 to promote wellness. DSHEA provided FDA with the
people, including a number of children. The FD&C Act regulatory authority and enforcement mechanisms to allow
led to a complete overhaul of the public health system, the access of supplements to consumers while providing

some level of protection. DSHEA specifically defined dietary Nursing consideration: Although the regulation of dietary
supplements as a category of food, while making it clear supplements is not as rigorous as for prescription or over-
that supplements would not be regulated as food additives. the-counter medications, certain requirements must be
Further, DSHEA mandated that dietary supplements met to legally market these products in the United States.
must be produced in compliance with current good When completing medication histories, nurses and nurse
manufacturing practices (cGMP). It is critical to note that practitioners should ensure that the supplements used by
the enhanced enforcement capabilities laid out in DSHEA their patients meet all applicable regulatory requirements.
gave FDA the authority to remove unsafe products from the Further, patients may benefit from discussing their therapeutic
market (Council for Responsible Nutrition [CRN], n.d.a.). objectives and available supportive data.
4. New dietary ingredient (NDI) notifications: As part of DSHEA,
it was established that dietary supplements that were in FDA has proposed that a listing be created describing all
commerce before 1994 could be considered safe based on products marketed as dietary supplements. Although FDA has
their history of use and can remain on the market without the authority to act against noncompliant products, there is
additional evidence of safety. All other dietary ingredients currently a problem with identifying all available products. Such a
will be considered “new” and will require that a formal registry would allow FDA to know when new products enter the
notice is provided to FDA with evidence that it is reasonably marketplace and provide the agency the tools needed to quickly
expected to be safe (NDI notification). If FDA has reason identify and act against dangerous products (Mister, 2020).
to suspect that the NDI is unsafe, it has the authority to
request additional information (FDA, 2019b). The 2015 Dietary Guidelines Advisory Committee (DGAC) was
5. Good manufacturing practices (GMP): This is a specific set formed as a joint effort of the U.S. Department of Health and
of rules and documentation that governs the manufacture Human Services (HHS) and the United States Department of
of dietary supplements. These guidelines, finalized in 2007, Agriculture (USDA) to evaluate dietary guidelines and identify
mandate high standards intended to ensure the consistent critical new research. An overarching objective was to develop
manufacture of dietary supplements. Dietary supplement food-based recommendations that were critical to good health.
GMP include guidelines stating that all ingredients are In a 2015 publication, these agencies noted that approximately
thoroughly tested for identity and purity, as well as requiring 50% of American adults suffered from a preventable chronic
products to meet prospectively determined quality disease. Further, they stated that about two of every three
specifications. Dietary supplement manufacturers are Americans were either overweight or obese. Although the
accountable to FDA to show proper documentation of all causes of these issues were multifactorial, poor dietary patterns
ingredients and processes. GMP documentation also covers were at least partly to blame, with the potential for positive
sanitation, batch records, training of employees, process changes to diet capable of influencing them (USDA, 2015).
validation, and release testing to document conformance to A national survey showed that more than 30% of adult
the product label (CRN, n.d.b.). Americans and about 12% of children employ healthcare
6. Dietary Supplement and Nonprescription Drug Consumer approaches that are outside of traditional Western medical
Protection Act (2006): This amendment to the FD&C Act practice. When such a nonmainstream practice is used together
requires the manufacturer, packer, or distributor whose with conventional medicine, it is termed “complementary
name appears on the label of a dietary supplement to healthcare.” This combined and coordinated practice is known
report within 15 days to the secretary of health and human as “integrative health” (NIH, 2018).
services any serious adverse event associated with the Complementary health approaches are often used to try to
use of its product. Further, this act requires that all related promote overall well-being rather than to try to manage the
records are maintained for a period of 6 years and that they symptoms of a health problem. Although nutritional supplement
will allow inspection of these documents (GovTrack, n.d.a.). use is a mainstay of complementary health, many people find
7. The Food Safety & Modernization Act (2011): This provision that combining it with other approaches, such as yoga, is helpful.
granted FDA the authority to issue a mandatory recall The state of wellness is multidimensional to include emotional
in the event that the manufacturer or distributor fails to welfare (coping and the creation of satisfying relationships)
enact a voluntary recall of a dietary supplement after being and physical well-being (the recognition of need for healthy
requested by FDA (CRN, n.d.b.). food, sleep, and physical activity). The National Center for
This current characterization states that a dietary supplement is a Complementary and Integrative Health has conducted research
product that meets the following requirements (NIH, 2020b): that suggests that people who employ complementary
● It is designed to supplement the diet. approaches with an aim towards wellness have better overall
● It is intended to be taken orally, formulated as a capsule, health than people who use complementary approaches to
tablet, liquid, gel cap, or soft gel. manage an existing health problem (NIH, 2020g). These findings
● It contains one or more dietary ingredient: vitamins, minerals, support the concept that supplements may be best suited
herbs, botanicals, amino acids, or other specific substances. for prevention of disease, in line with FDA regulations stating
● It has proper labeling identifying it as a dietary supplement. that dietary supplements are not intended to treat, diagnose,
prevent, or cure diseases.
NUTRIENT RECOMMENDATIONS: DIETARY REFERENCE INTAKES (DRI)
The Food and Nutrition Board is a component of the National Dietary reference intake (DRI) is a generalized term that describes
Academies of Sciences, Engineering, and Medicine (NASEM). the reference values for nutrient intakes in healthy individuals. In
As part of its task of ensuring nutritional well-being for all addition to their usefulness in assessing nutrient intakes, they can
Americans, it provides policy guidance designed to use nutrition also be employed to plan diets and supplementation strategies. It
and food science to enhance the health of Americans. Since its is critical to note that these values, in some cases, vary by sex and
establishment in 1940, the Food and Nutrition Board has been age. Multiple values are subsequently derived from DRI, including
evaluating myriad issues relevant to the adequacy and safety the following (NIH, n.d.):
of the US food supply. As a component of this nutritional study, ● Recommended dietary allowance (RDA): RDA is estimated to
it has provided authoritative perspectives on the complicated be an average level of a nutrient required every day to meet
relationships and the dependencies of food intake, health the nutrient needs of most (97% to 98%) healthy individuals.
maintenance, nutrition, and the prevention of disease (NASEM, ● Adequate intake (AI): In some cases, available evidence is
2018). inadequate to determine an RDA. In these instances, an AI is
established at levels thought to allow for adequate nutrition.
● Tolerable upper intake level (UL): Because many dietary Nursing consideration: Good nutrition is a cornerstone
supplements are not totally innocuous and may cause toxicity to good health. Nurses should incorporate a discussion of
at some levels, ULs are often characterized to represent nutritional needs into patient education. This conversation
the maximum daily intake that is unlikely to lead to adverse could begin with determining their patients’ diets and an
impacts on health. assessment to determine if they are obtaining the nutrients
needed through their diet. Based on this evaluation,
suggestions can be made for an appropriate regimen of
dietary supplementation.
CATEGORIES OF DIETARY SUPPLEMENTS

A wide variety of dietary supplements is marketed for Office of Dietary Supplements and can be accessed at https://
consumption to Americans, and they contain many ingredients ods.od.nih.gov/
intended to convey multiple benefits. For the purposes of FDA publishes a dietary supplement ingredient advisory list
this educational program, supplements covered are limited to designed to disclose to the public whenever FDA determines
those characterized by the National Institute of Health’s Office that certain ingredients used in dietary supplements do not
of Dietary Health as those commonly encountered: vitamins, appear to be lawfully used. Inclusion on this list is not necessarily
minerals, herbs/botanicals, amino acids, probiotics, and fish oil an indication that FDA has definitively concluded that the
preparations. Because of the large number of products available, ingredient is unsafe; rather, it means that FDA is working to
specific usage details are not included in this program. Instead, further evaluate its safety. This list is kept current by FDA and can
an overview of critical information that includes potential uses, be accessed at https://www.fda.gov/food/dietary-supplement-
supportive evidence, and safety issues is described. For details products-ingredients/dietary-supplement-ingredient-advisory-list
needed to guide the proper use of specific dietary supplements, (FDA, 2019a).
practitioners are advised to consult a reputable reference source.
A good overview of dietary supplements is provided by the NIH
Vitamins
Vitamins are a classification describing a category of organic be absorbed more readily in the presence of dietary fats
substances that are available in very small amounts in the food (MedlinePlus, 2020c).
that humans consume. Vitamins are critical to life; they help 2. The remaining nine essential vitamins are water soluble and
sustain normal metabolic processes. In cases where people cannot be stored by the body. As a result, these vitamins
do not ingest adequate amounts of vitamins, a variety of must be provided on an as-needed basis. Any surplus water-
pathologies may result. All vitamins are organic compounds, soluble vitamins are excreted. An exception is vitamin B12,
meaning that they contain the element carbon. Further, the which can remain in the liver for many years (MedlinePlus,
13 vitamins classified as essential cannot be generated by the 2020c).
body and must be obtained either through foodstuffs or dietary Each essential vitamin plays an important and unique role in the
supplementation (Brazier, 2017a). body’s proper function. In cases where a person does not receive
The 13 essential vitamins fit into two distinct categories: an adequate amount of a specific vitamin, a vitamin deficiency
1. Fat-soluble vitamins are able to accumulate in fatty may result. In some cases, deficiencies can lead to (sometimes
tissues throughout the body. The fat-soluble vitamins are serious) health problems (MedlinePlus, 2020c). The function of
vitamins A, D, E, and K. In many cases, these vitamins can each of the 13 essential vitamins is briefly described below.
Fat-soluble vitamins
Vitamin A (retinol, retinoic acid) is an important nutrient critical must be carefully considered in patients using anticoagulants
to vision, cell division, reproduction, and immunity. In addition, such as warfarin. It is critical to note that vitamin K deficiency in
vitamin A has antioxidant properties. Vitamin A naturally occurs adults is rare (Ware, 2019a).
in spinach, dairy products, and liver. When used as a dietary
supplement, it may benefit those with pancreatic disease, eye Evidence-based practice! Although vitamin D deficiency has
disease, or measles (Mayo Clinic, 2017d). been described in alarming terms, Cashman and colleagues
Vitamin D sometimes colloquially referred to as the “sunshine (2016) recognized that available vitamin D levels in European
vitamin,” is not actually a vitamin, but a prohormone (hormone people were of questionable quality. As such they set out
precursor) that can be made by the body if it is exposed to to systematically evaluate the literature with an eye towards
adequate levels of sunshine. In cases where not enough sunshine the NIH-led International Vitamin D Standardization program
exposure is appreciated, vitamin D supplementation is needed (VDSP). To estimate vitamin D levels across various age groups
because it is difficult to obtain adequate dietary vitamin D. in Europe, they examined a total of 18 well-controlled studies
Vitamin D facilitates calcium absorption and is thus useful in (reanalysis of 15 studies as well as new analysis of samples from
the promotion of healthy bones and teeth. Further, it supports three studies using a validated assay), providing a total sample
immune, brain, and nervous system health while helping to size of 55,844 participants. Using these datasets, investigators
regulate insulin levels (Ware, 2019b). obtained estimates of the prevalence of vitamin D deficiency.
When all of the data were pooled, irrespective of age or
Vitamin E functions as an antioxidant and occurs naturally in a ethnicity, their data showed that 13% of the study participants
variety of foods such as nuts, seeds, and leafy green vegetables. were vitamin D deficient (< 30 nmol/L), on average, over the
Vitamin E is critical for a variety of bodily functions, to include course of the year. Quite different results were obtained when
the creation of red blood cells and the proper facilitation of evaluated by season: 18% were deficient in the winter; 8% were
vitamin K (Drugs.com, 2019). deficient in the summer. When participants were classified by
Vitamin K is involved in blood coagulation, bone metabolism, skin pigmentation, analyses showed that dark-skinned ethnicities
and the regulation of calcium levels in the body. A key role of had higher (threefold to seventy-onefold) levels of vitamin D
vitamin K is to facilitate production of the blood clotting factor compared to fair-skinned participants. Investigators concluded
prothrombin. As a result of its potential to impact clotting, that vitamin D deficiency is evident throughout Europe at
vitamin K, both through dietary and supplemental ingestion, concerning rates of prevalence requiring public health action.

Water-soluble vitamins
Biotin is one of eight B vitamins, sometimes called vitamin B7 or associated with healthy skin. Typically, pantothenic acid is used
vitamin H, stemming from the German words haar and haut (hair in combination with other B vitamins. Although there is not
and skin). Biotin is required by the body to facilitate the function solid, convincing evidence of its efficacy, it is commonly taken
of a number of enzymes called carboxylases. These enzymes to prevent acne, allergies, baldness, asthma, and many other
are critical to a number of metabolic processes, to include the maladies (eMedicineHealth, 2019).
production of glucose and fatty acids. These reactions are useful Riboflavin, sometimes called vitamin B2, works in concert
for maintaining healthy nails and hair as well as supporting with the other B vitamins. Specifically, riboflavin is associated
pregnancy and breastfeeding. Fortunately, because biotin with proper growth and the production of red blood cells
exists in a wide variety of foods, deficiencies are rare, with (MedlinePlus, 2020c).
the exception of some pregnant women and heavy drinkers
(Palsdottir, 2020). Thiamine (vitamin B1) helps the body to use carbohydrates for
energy, also playing important roles in the function of nerves,
Niacin, also known as vitamin B3, is naturally present in many the heart, and muscle. It is well established that thiamine
foods such as poultry, beef, fish, legumes, and grains. All the requirements increase during pregnancy and lactation. Meat,
body’s tissues are able to convert niacin into its active form, fish, and grains all serve as good sources of thiamine. In some
the coenzyme nicotinamide adenine dinucleotide (NAD). cases, white flour and breakfast cereals are enriched with
NAD is critical to life, with more than 400 enzymes needing it thiamine. Because thiamine is not stored in the body, humans
to function properly. In cases of severe niacin deficiency, the require a constant supply. Thiamine deficiency is associated with
disease pellagra may occur, marked by a pigmented rash on skin the disease beriberi, manifested by peripheral nerve problems
exposed to sunlight, sometimes also manifesting with neurologic and wasting (Brazier, 2017b).
symptoms. Fortunately, pellagra is rare in the developed world,
mostly limited to people living in poverty (NIH, 2020d). Vitamin B6 (pyridoxine) participates in many bodily functions
and is involved in more than 100 separate enzyme reactions,
Folic acid (sometimes referred to as folate) works in concert with many critical to protein metabolism. Although present in many
vitamin B12 to assist in the formation of red blood cells. Further, foods, the richest sources of vitamin B6 are fish, beef liver and
folate is required in the production of DNA; it subsequently other organ meats, potatoes, and fruit. It is critical to note that
controls the growth of tissues and cell function. In pregnant glycosylated forms exist in some fruits, vegetables, and grains,
women, low levels of folate are associated with birth defects reducing its availability for absorption. Vitamin B6 deficiency is
such as spina bifida. As a result, a number of foods are fortified associated with microcytic anemia, weakened immunity, and a
with folate to ensure adequate dietary folate (MedlinePlus, variety of other pathologies (NIH, 2020f).
2020c).
Vitamin B12 (cyanocobalamin) is needed to maintain the
Nursing consideration: In addition to promoting good proper function and development of the brain, nerves, blood
nutrition in all patients, it is critical that nurses caring for cells (deficiencies may result in pernicious anemia), and a
pregnant women stress the importance of folic acid. In variety of other body systems. It is also useful in the treatment
addition to fortification in many foods, multivitamins that are of cyanide poisoning and hyperhomocysteinemia. Vitamin
designed for pregnant women typically contain additional folic B12 can be found in meat, fish, and dairy products. In some
acid. cases, vitamin B12 is synthesized in a laboratory (WebMD,
n.d.d.). Deficiencies in vitamin B12 may lead to a variety of
Pantothenic acid, sometimes called vitamin B5, is found in neuropsychiatric problems, including gait abnormalities and
a variety of foods, to include meat, vegetables, grains, and behavioral disturbances. Psychiatric manifestations of vitamin
eggs. This vitamin is implicated in the proper metabolism of B12 deficiency may be related to abnormal neurotransmitter
carbohydrates, proteins, and lipids. Further, it is sometimes transmission, hyperhomocysteinemia, and increased levels of
methylmalonic acid (Kerkar, 2018).
Case study 1
Advanced Practice Nurse (APN) Dan is caring for a 2-year-old so he considers treatment with vitamin B12. In this case Dan
patient, Will. Notable medical history showed that he suffers administered a dose of vitamin B12. Within a week of daily
from granuloma annulare and nearly continuous constipation. injections, Will’s demeanor had changed drastically. He had
In addition, as a newborn he was given a diagnosis of moved from a violent and depressed state to one of happiness
gastrointestinal reflux disease (GERD), which persisted until he and content. Will’s parents were in shock by the seemingly
was about 6 months old. He began walking at around 9 months impossible change to their previously distressed and crazy life.
of age but soon developed ataxia. A brain MRI at the time
showed no obvious issues. About the time Will turned 1 year Self-Assessment Quiz Question #1
old, he began to experience behavioral problems, including
irritability and an extremely harsh temper. He often woke in the In the case of Will, it appears most evident that the main
night screaming, which worsened as he grew older. Will began consequence of vitamin B12 deficiency was manifested by
self-harming at age 18 months and suffered from frequent behavioral issues. Nonetheless, this deficiency could also be
violent outbursts. After his second birthday, the violence associated with other problems. What are some examples of
escalated, and he began biting and kicking anyone who came things that Dan should look into?
near him. A qualified behavioral therapist was astonished and a. Blood cell development. If Dan did not obtain a complete
unable to provide useful guidance. His previous pediatrician blood count, he should.
determined that Will was likely suffering bipolar disorder and b. Kidney dysfunction.
c. Visual field disturbances.
oppositional defiant disorder (ODD).
d. Adrenal function.
Dan has a special interest in treating children with behavioral
issues and was not certain that he agreed with the initial
diagnoses. He began his assessment by collecting blood for a
variety of tests to see if he could identify a biochemical rationale
for Will’s behavior. All of the test results came back within the
reference range. Dan took interest in the serum B12 value,
nonetheless, since it was near the lower limit. He was aware
that this test’s reference range is inaccurate in some cases,
A critical concept is the proper dose levels of essential vitamins,
Self-Assessment Quiz Question #2
especially in cases of fat-soluble vitamins that can accumulate to
What can an astute nurse learn by observing Dan’s care of Will? potentially toxic levels in the body. In general, patients should
a. Clinical laboratory levels are rarely useful as diagnostic tools. follow vitamin RDA when considering proper dosages of dietary
b. Clinical laboratory reference ranges are based on a supplements containing vitamins. Naturally, clinicians may suggest
population of patients and may not represent normal for all different levels for some patients depending on their individual
individuals. needs (MedlinePlus, 2020c). RDA may vary by age or sex; current
c. In many cases a second clinical opinion can provide value to
RDA are described in a table provided by the Food and Nutrition
making the correct diagnosis.
d. Both b and c. Board of the Institute of Medicine, National Academies that can
be found at https://www.nal.usda.gov/sites/default/files/fnic_
Vitamin C (ascorbic acid) is acknowledged as an antioxidant that uploads//RDA_AI_vitamins_elements.pdf
is useful in the promotion of healthy teeth and gums. Additional
roles of vitamin C are to assist in the absorption of dietary iron, Nursing consideration: It is critical for nurses and nurse
the maintenance of healthy tissue, and promotion of proper practitioners to distinguish between water- and fat-soluble
wound healing (MedlinePlus, 2020c). In the early 1970s, Linus vitamins relative to their ability to accumulate in the body.
Pauling, a winner of the Nobel Prize, proposed the theory that Unfortunately, the human mindset is often based on the
vitamin C administered as megadoses (up to 18,000 mg per premise that more is better. As such, massive doses of vitamins
day) is helpful in the prevention of colds. To confirm/refute are not uncommon. In the case of water-soluble vitamins such
this theory, many clinical studies were conducted examining as vitamin C, surplus vitamins are typically excreted in urine.
supplementation with 200 mg or more vitamin C. Overall, these Although this is economically wasteful, this is usually benign
studies were unable to show reduced risk of catching a cold. from a safety perspective. In contrast, elimination of fat-soluble
Nonetheless, data do support that vitamin C supplementation vitamins is more difficult, meaning that excess vitamins can
can sometimes make a cold less severe and modestly shorten its accumulate in the body. In extreme cases toxicities may result.
duration. Some data suggest that 6 to 8 grams of vitamin C per This is important educational material that nurses should
day can shorten the duration of a cold in adults by about 18% discuss with their patients.
(Gunnars, 2018).
Case study 2
Nurse Jeanine is a staff nurse at small college health center.
Today she is meeting with a new student, Gerri, who has come Self-Assessment Quiz Question #4
to her for some advice on how to prevent and manage the cold
Although MegaRed appears to rely on relatively high doses
and flu season. In addition to taking a full course load, Gerri
of most vitamins, each tablet provides only 33% of the
works the predawn shift at a local bakery for extra spending
recommended dietary allowance for vitamin A. What would be
money. She realizes that all of this work has created high levels
a plausible reason for this difference?
of stress, and she is thus concerned for her health going into a. Vitamin A has been proven to have little impact on colds.
the fall cold and flu season. Her multiple commitments make it b. The relatively high dose of vitamin C is compensatory.
very important that she not lose time because of illness, further c. Vitamin A is fat soluble allowing the possible accumulation
adding to her stress levels. Specifically, Gerri is interested of supertherapeutic doses.
in Jeanine’s insights on a new supplement called MegaRed d. Vitamin A is minimized because as an ingredient it is cost
designed to prevent colds, flu, and a variety of other ailments. prohibitive.
Although one of her friends highly recommended it, Gerri
remains skeptical. Gerri learned through an Internet search
that the supplement facts label showed that each MegaRed Self-Assessment Quiz Question #5
tablet contained (as a percentage of RDA) 33% for vitamin A;
It appears that the most prevalent (largest dose) ingredient in
700% for vitamin C; 200% for niacin; and 100% for vitamin B6.
MegaRed is vitamin C. Why do you think that is?
The label suggested that she take two to three tablets daily to a. Some data suggest that vitamin C can reduce the duration
maintain good health and another two to three tablets every 3 of a cold.
hours at the first sign of feeling unwell. To this point the product b. Other data show that vitamin C may decrease the severity
seemed to make sense to Gerri until she clicked on the “buy of a cold
now” button and found that 100 tablets, described as a month’s c. Both a and b.
supply, cost $79.99. This seemed like a lot of money to Gerri, d. Vitamin C is proven to prevent colds.
thus motivating her to get Jeanine’s opinion. Jeanine, sharing
Gerri’s skepticism, decided to turn it into a teaching moment
by asking Gerri a series of questions to see how well she Self-Assessment Quiz Question #6
understood vitamins and how to use them.
The cost of $79.99 for a one-month supply of MegaRed may
be considered exorbitant to some individuals. Provide a
Self-Assessment Quiz Question #3 plausible explanation for the relatively high cost.
When MegaRed is used as directed, which of the vitamin a. The product is aggressively marketed, and the
manufacturers suspect that the relatively high cost will
ingredients will provide all that Gerri likely needs daily, based
suggest high quality.
on the recommended dietary allowance? b. The ingredients contained in MegaRed are uncommon and
a. Niacin. thus expensive.
b. Vitamin B6. c. The cost is required to recoup company research and
c. Vitamin C. development efforts.
d. All of the above. d. The cost is largely driven by the relatively high dose of
vitamin C.
Minerals
Dietary minerals work hand in hand with vitamins to provide main classifications based on how much the body requires:
complete nutrition. Minerals are needed for heart and brain macroelements (large amounts required for proper nutrition:
function as well as the generation of certain hormones calcium, phosphorous, sodium, potassium, chloride, magnesium)
and enzymes. Dietary minerals can be broken into two and microelements (trace amounts needed: iron, nickel, zinc,

fluoride, copper, chromium, manganese, selenium, iodine, toxic, even fatal, especially in young children (National Health
molybdenum). Though an adequate quantity of minerals Service [NHS], 2020).
can usually be obtained with a healthy balanced diet, some Nickel: Although nickel’s exact mechanism of action is not well
populations may require supplementation. Candidates for understood, it is useful in aiding the absorption of iron and
mineral supplementation include pregnant women, nursing treating osteoporosis. Although nickel deficiencies have not
mothers, vegans, people who depend excessively on processed been reported in humans, low nickel levels have been observed
food, and older individuals (Kubala, 2020). in animals (WebMD, n.d.c.).
Key dietary minerals and their function are listed below. Zinc is extremely important to good health. It impacts the
Macrominerals immune system, cell division, and DNA synthesis. Although zinc
Calcium, the most common mineral in the body, is needed to deficiencies have been observed in people with insufficient intake,
form bones and teeth, for muscle function, nerve transmission, poor absorption, alcoholism, those with certain gene mutations,
and hormonal secretion. Most (99%) of the body’s calcium is and the elderly, in most cases it is easy for people to consume
stored in the bones and teeth. The body maintains the proper adequate zinc in their diet. Like many things, though, too much
levels of calcium through constant resorption and deposition of zinc can result in adverse events such as nausea and vomiting,
calcium in the bones. In younger people, deposition generally headaches, and decreased HDL cholesterol (Kubala, 2018).
exceeds resorption. The opposite is true in older people, Fluoride aides in the development of strong bones and teeth.
especially postmenopausal women (NIH, 2020a). Fluoride is likely best known for its role in strengthening the
Phosphorus is second only to calcium in terms of abundance enamel that protects teeth. It is critical to note that excess
in the body, with which it works closely to construct strong fluoride ingestion has been linked to a variety of health issues,
bones and teeth. Smaller amounts of phosphorus can be such as dental fluorosis (tooth discoloration), skeletal fluorosis
found in tissues throughout the body. This mineral also plays (decreased elasticity leading to pain and increased fracture risk),
a key role in the storage and usage of energy, as well as the problems with the parathyroid, and some neurological issues
growth, maintenance, and repair of tissues and cells. Although (Brazier, 2018).
most people will get plenty of phosphorus in their diet, some Copper is present in all body tissues and works in concert
health disorders can lead to decreased levels in the body. with iron to form red blood cells. In most cases dietary copper
Further, anorexia and the use of some antacids can also cause is adequate. In cases of low levels of copper, anemia or
phosphorous levels to drop (WebMD, 2020b). osteoporosis can result. In excess, copper can be toxic, leading
Sodium: The body requires some sodium to support the proper to hepatitis and kidney and brain issues (MedlinePlus, 2020a).
function of nerves and muscles and maintain a proper fluid Chromium has a variety of roles in the body, including the
balance, but most people receive too much sodium in their digestion of food. The presence of chromium may help slow the
diets. Increased sodium levels can result in hypertension, which loss of calcium, to the benefit of people at risk of osteoporosis.
can lead to a variety of pathologies. Rather than supplementing It is critical to note that there is extensive commercial promotion
sodium, most patients require assistance in limiting their intake of chromium as an aid in the building of muscle and burning fat.
of this mineral. This is especially important in people with high Nonetheless, there is inadequate available data to support these
blood pressure, diabetes, and kidney problems; those who are claims (WebMD, n.d.b.).
African American; and people over age 50 (MedlinePlus, 2020b).
Manganese is present mainly in the bones, liver, kidneys, brain,
Potassium is an electrolyte, meaning that it can conduct and pancreas. Manganese is vital to a variety of functions,
electricity in the body. As such it is crucial to proper heart to include amino acid, cholesterol, and glucose metabolism.
function and is required for skeletal and smooth muscle Further, it is involved in the formation of bone, the clotting of
contraction. Potassium is found in a wide variety of foods, blood, and inflammation reduction. In addition to being found
making supplementation unnecessary for most individuals. It in many foods, manganese can sometimes be derived from
is important to maintain proper potassium blood levels; both drinking water. Deficiencies are rare, nonetheless, and are
too much (hyperkalemia) or too little (hypokalemia) can be sometimes associated with reduced glucose tolerance, fertility
dangerous. A variety of pathologies can cause hypokalemia; problems, and other issues. It is important to note that it is much
hyperkalemia is more prevalent in older individuals. Lastly, a more likely that a person would suffer from overexposure to
variety of medications can impact potassium levels in some manganese than a deficiency (Fletcher, 2019).
patients (Weatherspoon, 2019).
Selenium, naturally available in a variety of foods, plays a critical
Chloride can typically be found in the body in conjunction with role in thyroid hormone metabolism, reproduction, and DNA
sodium and water. It is useful to maintain the proper osmotic synthesis, as well as in providing protection from oxidative
pressure of body fluids and is a critical partner to hydrogen in damage and infection. The major body storage site for selenium
the formation of hydrochloric acid, a key digestive acid. Chloride is in skeletal muscle, which accounts for 28% to 46% of the total
is excreted or retained by the kidneys to maintain proper levels body’s pool. Although most people obtain adequate selenium
(Haas, n.d.). in their diet, deficiencies can generate biochemical changes
Magnesium is required as a component for more than 300 that may leave some people vulnerable to stresses that can
biochemical reactions in the body. For example, it is important in predispose them to certain illnesses. Selenium is contained in
the maintenance of nerve and muscle function, immune system, most multivitamin supplements (NIH, 2020e).
heart rhythm, and bones. Most people get enough magnesium Iodine is an essential part of the thyroid hormones thyroxine (T4)
in their diets and supplementation is not generally indicated. and triiodothyronine (T3). Thyroid hormones are involved in the
It is rare that a person is ever truly magnesium deficient regulation of several critical biochemical reactions in the body,
(MedlinePlus, 2019). including enzymatic activity, protein synthesis, and the regulation
Microminerals of metabolic activity. Further, thyroid hormones are needed to
Iron is needed by the body to make red blood cells. As a result, ensure the proper perinatal development of the skeletal and
a lack of iron can lead to iron deficiency anemia. Though an nervous systems (NIH, 2020c).
adequate amount of iron can usually be obtained from the diet, Molybdenum plays a role as a cofactor for at least four essential
some people may require supplementation. As an example, enzymes, including sulfite oxidase. Sulfite oxidase works to
women who lose a large amount of blood during their menstrual help degrade the sulfites that occur in a number of chemically
cycle are at a higher risk of iron deficiency anemia and may be preserved foods and specific proteins. Even though most of this
good candidates for supplementation. High doses of iron can be mineral is absorbed and stored in organs, some is converted
to molybdenum cofactor, and excess is excreted in the urine.
As with many vitamins and minerals, true deficiencies are rare, Current RDA are described in a table provided by the Food and
although long-term molybdenum deficiencies have been linked Nutrition Board of the Institute of Medicine, National Academies
to esophageal cancer (Rowles, 2017). that can be found at https://www.ncbi.nlm.nih.gov/books/
Just as with vitamins, it is critical that proper levels of essential NBK56068/table/summarytables.t3/?report=objectonly
minerals are maintained and supplemented only in cases where
indicated by documented low-blood levels. This is especially Nursing consideration: For most patients, an adequate
important in situations where minerals can accumulate to amount of all essential vitamins and minerals can be
potentially toxic levels in the body. In general, patients should obtained with a daily multivitamin. As a result, an investment
follow vitamin RDA when considering proper dosages of in multivitamins may be the most cost-effective health
dietary supplements containing minerals. Naturally, healthcare intervention for many patients. Nurses should consider sharing
professionals may suggest different levels for some patients this insight as part of their approach to patient education.
depending on their individual needs; RDA varies by age and sex.
Herbs/botanicals
Herbs and botanicals are plants or parts of plants that some the treatment of certain seizures (Epidiolex) and in combination
patients use either as a treatment or preventive measure. Such with THC (Sativex) for the treatment of multiple sclerosis in 25
products are formulated in teas, capsules, tablets, liquids, or countries outside of the United States (WebMD, n.d.a.).
powders. It is critical to note that, although these supplements CBD has been shown to have the potential to interact with a
are generally natural products, they are not always safer than large number of medications, both through modulation of at
prescription medications because they may be quite foreign least two common metabolic enzymes and a key protein involved
to the human body. As a result, many of these products can with the absorption and excretion of drugs (P-glycoprotein). As
be strongly impactful – sometimes causing serious adverse a result, the potential for CBD drug interactions with commonly
events. Some research has been conducted to characterize a few used medications is great. Although a comprehensive list of all
herbal/botanical products, but in most cases, a comprehensive potential drugs is beyond the scope of this educational program,
understanding of the potential risks and benefits has not been a list of medications with the potential to interact with CBD can
achieved. Because these dietary supplements are classified be found in Brown and Winterstein’s review article (2019): https://
by FDA as food, their safety and efficacy are not required www.mdpi.com/2077-03/8/7/989
to be proven. It is also important to know that some patient
subpopulations can be at an increased risk of adverse events Spirulina is a variety of blue-green algae considered by some
from herbal/botanical dietary supplements. Examples include to be a superfood. Spirulina, high in protein and vitamins, is
those who are pregnant or breastfeeding or who have certain suitable for vegetarians. Some research has suggested that it
medical conditions. Some herbal products may cause problems has antioxidant properties and may be capable of regulating
with surgery, such as excessive bleeding. Further to that, some the immune system. People may take spirulina to aid in weight
herbal products have the potential to impact the disposition of loss, improvement of gut health, managing the symptoms of
other medications. For instance, St. John’s wort can affect the diabetes, reduction of cholesterol, controlling blood pressure,
metabolism of a large number of medications, decreasing their prevention of heart disease, increasing basal metabolism,
concentrations and subsequent effects. It is always critical to reduction of allergy symptoms, and supporting mental health
discuss the usage of all supplements with appropriate healthcare (Burgess, 2018).
professionals (Family Doctor, 2020). Although the literature contains a number of nonclinical and
small human trials providing some evidence of effect, current
Nursing consideration: Many patients do not consider dietary
knowledge can only suggest that spirulina is a safe food
supplements when asked about their medications. Because
supplement without significant side effects. Its effectiveness is
of the potential pharmacologic properties of these products,
yet to be definitively established.
especially herbal products, it is critical to specifically address
supplements when obtaining medication histories. St. John’s wort (Hypericum perforatum) is a European flowering
shrub. The flowers and the leaves of this plant are known to
Like all medications and dietary supplements, the FDA requires contain a pharmacologically active chemical called hyperforin.
that herbal/botanical products are accurately and truthfully Unlike many other herbal/botanical supplements, reasonable
labeled. Labeling must include its name, manufacturer/distributor, clinical evidence has been generated to demonstrate its
a complete list of ingredients, and the quantity contained in the potential efficacy in the treatment of mild to moderate cases of
package. In addition, proper directions for safe usage should be depression. In fact, some investigations suggest that it may incur
included. Any products that do not have this information on the efficacy on the magnitude of some prescription antidepressant
label should be avoided. If a dietary supplement is found to be medications. A potential pitfall to the use of St. John’s wort is
unsafe or is mislabeled, FDA is empowered to remove it from the its drug interaction potential. St. John’s wort reacts not only
marketplace. Patients who decide to take these products should with antidepressants, but also with anticoagulants, birth control
use the products as directed and in the recommended amounts medications, HIV/AIDS medications, and many others. As a
(Family Doctor, 2020). result, its use may be hazardous in patients using concomitant
Although hundreds of different herbal/botanical dietary medications (Mayo Clinic, 2017c).
supplements are available, some of the more common herbal Turmeric is a spice that is commonly used to color curries,
supplements include the following. mustards, and other foods. Turmeric root is also widely used
Cannabidiol (CBD), a component of marijuana, has been shown as an alternative medicine, possibly aiding in reduction of
to have effects on the brain through unknown mechanisms. cholesterol, treatment of pain from osteoarthritis, and treatment
Apparently, it impacts pain, mood, and mental function. of stomach ulcers, rheumatoid arthritis, tuberculosis, Alzheimer’s
Preliminary research has shown that CBD may be effective for a disease, cancer, and inflammatory bowel disease (Multum, 2019
variety of disorders, to include bipolar disorder, Crohn’s disease, The literature contains a number of nonclinical and small human
diabetes, dystonia, fragile-X syndrome, graft versus host disease, trials providing some evidence of effect, but current knowledge
Huntington’s disease, and insomnia. At this time, though, none can only suggest that turmeric is a safe food supplement without
of these indications has been proven out in properly powered, significant side effects. Its effectiveness is yet to be definitively
randomized, controlled clinical trials (WebMD, n.d.a.). established.
Nonetheless, specific CBD products have been shown to be
safe and efficacious and thus approved as prescription drugs for

Nursing consideration: Many patients do not consider dietary Evidence-based practice! Apaydin and colleagues (2016)
supplements when asked about their medications. Because conducted a systematic review of the scientific literature to
of the potential pharmacologic properties of these products, assess the safety and efficacy of St. John’s wort (SJW) for the
especially herbal products, it is critical to specifically address treatment of major depressive disorder (MDD) compared to
supplements when obtaining medication histories. both placebo and active control. They considered randomized
controlled trials (RCT) employing at least a 4-week treatment
period. A total of 35 published clinical trials enrolling a total
of 6,993 patients met their criteria and were included in their
analyses. Results showed a response rate for SJW-treated
patients that was 53% higher than those who received
placebo (16 RCT enrolling 2,888 patients). Reported adverse
events were similar between SJW-treated and placebo-
treated patients with the exception of those related to the
eye, ear, nervous, hepatic, renal, and reproductive systems.
Investigators noted that assessments of adverse events across
studies were limited, lowering the quality of evidence. When
SJW-treated patients experienced fewer adverse events,
investigators concluded that SJW monotherapy is superior to
placebo and not significantly different from antidepressant
medications for the treatment of mild to moderate depression.
Case study 3
Mary M. is an 83-year-old woman with a history of hypertension Pomegranate juice and extract: Pomegranate (Punica granatum)
and myocardial infarction. She is visiting with her APN, Jenny. is a tree bearing fruit native to Western and Central Asia with a
Midway through their conversation, Jenny realizes that Mary long history of being grown in temperate climates worldwide.
seems a bit different than she remembers, somehow lacking the It can be consumed as a fruit, juice, or extract product.
sparkle in her eye and the normal wit in her expression. After a Pomegranates, enjoyed for millennia, were always thought of
bit of probing, Mary communicates that she has not felt normal as having health benefits. Pomegranates are a good source
lately. More specifically, she feels a bit down after the holidays. of vitamin C, vitamin K, iron, calcium, potassium, and folate.
After she thought about it a bit, she admitted that this always Recent scientific research suggests that pomegranates also
happens in January. Jenny realized the importance of listening possess multiple key properties that may be beneficial to health.
at this point, so she allowed Mary to continue. Eventually, Mary Many of these health claims are based on multiple polyphenolic
asked Jenny if she thought that she might be suffering from compounds found in the pomegranate. These phytochemicals
depression. She said that she had been discussing her feelings have been shown to act as antioxidants, impacting numerous
with a close friend, who said she often feels the same and feels body systems. Some examples of potential benefits include
better after taking St. John’s wort. Now that Jenny was thinking reduction of cholesterol and plaque buildup in artery walls
about it, she realized that Mary could be suffering from a seasonal and reduction of inflammatory cytokines, and decreasing the
type of depression. Rather than going straight to a prescription symptoms of osteoarthritis, rheumatoid arthritis, and other
antidepressant medication, Jenny wondered to herself if Mary inflammatory diseases. Despite these potential benefits and
might be a good candidate for a trial with St. John’s Wort. a relatively benign adverse event profile, pomegranate has
Jenny had read publications that suggested that this herbal the potential to interact with multiple medications, to include
product can be as effective as conventional antidepressants and, warfarin, enalapril, and other ACE inhibitors (WebMD, 2020a).
because it is a natural product, perhaps it might be safer. She Animal models have shown that some pomegranate
quickly reviewed a recent review article focused on the use of components inhibit the metastasis of ovarian cancer by way
St. John’s wort for mild to moderate depression and reviewed of downregulating multiple matrix metalloproteinases. When
Mary’s current medications. Mary was taking lisinopril 10 mg, pomegranate’s effect on prostate cancer cells was evaluated,
hydrochlorothiazide 25 mg, and clopidogrel 75 mg. a similar effect on matrix metalloproteinases was observed,
inducing apoptosis and impairing metastasis. Work with a
Self-Assessment Quiz Question #7 pomegranate extract product suggested a prevention of breast
Which of the following statements about St. John’s wort is cancer through multiple anti-inflammatory processes. Although
FALSE? these preclinical data are encouraging, more extensive clinical
a. Although it is an herb, it has pharmacologically active research is required for confirmation of effect (Memorial Sloan
properties. Kettering Cancer Center [MSKCC], 2019).
b. According to some clinical studies, its efficacy against
mild to moderate depression is similar to that afforded by Evidence-based practice! Decreasing prostate specific
prescription antidepressants. antigen doubling time (PSADT) is generally associated with
c. No adverse events are associated with the use of St. John’s increased risk of prostate cancer recurrence. Paller and
wort. investigators (2013) conducted a double-blind, placebo-
d. St. John’s wort has the potential to interact with other controlled trial in 104 recurrent prostate cancer patients with
medications. decreasing PSADT. Subjects were randomized to receive
either 1 or 3 grams of pomegranate extract daily for up to 18
months. Data showed that PSADT was elongated from 12 to
Self-Assessment Quiz Question #8 19 and 12 to 18 months in the low- and high-dose groups,
It has been established that St. John’s wort should be treated respectively (p < 0.001). There was no statistical difference
between the two dose levels (p = 0.554). PSADT increases
like a prescription medication. Before prescribing it, drug > 100% were observed in 43% of patients, and declining
interactions with existing medications must always considered. PSA levels were observed in 13% of patients. Although no
Which of Mary’s concomitant medications has the greatest significant adverse events were observed in either group, the
chance of interacting with St. John’s wort? incidence of diarrhea was higher in the high-dose group (14%
a. Lisinopril. vs. 2%). Investigators concluded that, although significant
b. Clopidogrel. increases in PSADT were observed at both dose levels, these
c. Hydrochlorothiazide. results need to be confirmed in a placebo-controlled trial.
d. None of the above.
Amino acids
The Internet is awash with opportunities to purchase a wide
variety of amino acid-based dietary supplements designed Evidence-based practice! Wolfe (2017) noted that a lucrative
to improve health. In one recent article describing the use of industry has formed based on the hypothesis that BCA, given
these products, amino acid supplements are purported to offer alone, are able to drive an anabolic response in humans that
health benefits for people wanting to replenish their bodies stimulates the synthesis of muscle protein. His review of the
after a workout or just remain healthy. The manufacturer’s literature revealed no studies in humans where the response
argument states that these supplements contain the essential of muscle protein synthesis was observed as a result of orally
amino acids – those that the body cannot make – needed to ingested BCA. Nonetheless, he identified two studies where
form necessary proteins. The idea is that there is a need to BCA were administered via intravenous infusion. In these
supplement the dietary input of amino acids. Thus, amino acid examinations, a decrease in muscle protein synthesis coupled
supplements serve as a sort of insurance policy to ensure that to protein breakdown was correlated to BCA administration.
the body receives all of the amino acids needed. Further, it is These findings, then, suggest a decrease in the turnover of
theorized that the supplements are required at times of elevated muscle protein. In other words, muscle protein catabolism
protein demand, such as during illness or when recovering from exceeded the rate of new muscle synthesis during BCA
an injury. Amino acid supplements are broken down into two infusion. He theorizes that muscle synthesis is rate limited
distinct categories: branched-chain amino acids (BCA) (contain by the lack of other essential amino acids. In summary, the
leucine, isoleucine and valine, potentially the most studied author concluded that the claim of BCA, administered alone,
amino acids used for dietary supplementation), and those that stimulating muscle protein synthesis in humans is unwarranted.
are designed to be high in arginine and glutamine. Because The findings of Wolfe leave open the possibility that if BCA
33% of skeletal muscle is composed of BCA, it follows that could be combined with other essential amino acids, a positive
they may play a role in exercise recovery. The single amino acid effect on muscle recovery could be realized. Unfortunately, such
supplements arginine and glutamine are described as offering supplementation must be empirically based, as there are no
specific health benefits. Arginine, an essential amino acid, can be reputable data available to support this hypothesis.
converted to nitric oxide, which relaxes blood vessels and may
be useful in the management of high blood pressure. Glutamine, Nursing consideration: There is little evidence available to
which is not essential, is thought to assist in wound healing and support the use of amino acid-based dietary supplements in
reducing the rate of infection (Annigan, 2018). most patients. Nurses may find that some of their patients
Additional amino acid supplements intended to provide health are strong believers in the benefit of these products. In some
benefits include L-tryptophan, aspartate, orthenine, lysine, cases, however, it may be useful to have a tactful, yet direct,
tyrosine, and taurine (Annigan, 2018). conversation with their patients regarding the potential
Unfortunately, the scientific literature does not contain a shortcomings of these products.
large body of research to solidly document the utility of these
supplements (Annigan, 2018).
Probiotics
Probiotics are bacteria that are ingested in an effort to maintain fully understand the safety of probiotics in immunocompromised
a proper balance of intestinal microflora. The gastrointestinal (GI) young and older individuals (WebMD, 2020c).
tract typically hosts approximately 400 species of bacteria that Acidophilus (Lactobacillus acidophilus) is native to humans within
act in concert to crowd out harmful bacteria. When functioning as the mouth, the GI tract, and the vagina. It is also a common
intended, these organisms help maintain a healthy digestive tract. dietary supplement ingredient. Acidophilus is found in a variety
Assessment of the GI tract demonstrates that the most common of dairy products, such as yogurt, and is generally formulated
probiotic bacteria are of the lactic acid variety. The most common for use as a supplement in capsules, tablets, wafers, powders,
species is Lactobacillus acidophilus, which is also found in live and as vaginal suppositories. It is commonly used in an effort to
yogurt cultures. Other common organisms are classified within the prevent or treat bacterial vaginosis and various digestive issues,
yeast family. Many species are available as dietary supplements as well as to simply promote the growth of beneficial GI bacteria.
and are intended to treat a variety of gastrointestinal problems.
Some people take probiotics in an effort to prevent the diarrhea, A large amount of clinical research has been conducted in an
gas, and cramping that often accompany the use of certain effort to promote the benefits of acidophilus. Efficacy has been
antibiotics. The theory behind this practice is that antibiotics demonstrated in the treatment of bacterial vaginosis. Data have
often kill “good” bacteria, allowing opportunistic “bad” bacteria also been generated supporting its use in the treatment of
to flourish. This is thought to result in gastrointestinal distress, respiratory infections and some varieties of diarrhea, bloating,
overgrowth of vaginal yeast, and urinary tract infections. The aim and cramps caused by antibiotic usage, to include the more
of probiotics is to replace the bacteria lost as collateral damage to serious C. difficile-induced diarrhea. Oral acidophilus may also
antibiotic therapy (WebMD, 2020c). be beneficial during pregnancy and breastfeeding to reduce the
occurrence of atopic dermatitis in infants and young children
It is critical to note that only certain species of yeast and who are breastfeeding. One issue with the use of acidophilus is
Lactobacillus are beneficial. Further research is needed to clearly a lack of standardization among available supplements, which
demonstrate which specific probiotic species are effective at complicates the proper dosing of this probiotic as a dietary
treating disease. Further, many of the species with demonstrated supplement. Although additional research is required to provide
efficacy are not widely available in practical supplement the data needed to guide the proper use of acidophilus,
formulations. The majority of probiotics are composed of available evidence suggests that there is little harm in using
organisms native to the body and have been consumed for many these products. Nevertheless, ingestion of a balanced diet that
years in the form of fermented foods and cultured milk products. includes fermented foods may provide adequate levels of these
As a result, these products do not raise significant safety concerns. useful bacteria (Mayo Clinic, 2017a.).
Nonetheless, it is evident that additional research is needed to
Fish oil
Fatty fish and some shellfish contain polyunsaturated fatty acids, most abundant omega-3 fatty acids are alpha-linolenic acid
collectively known as omega-3 fatty acids. Omega-3 fatty acids (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid
are critical to a variety of functions in the human body. The (DHA). ALA is prevalent in vegetable oils, especially canola and
Page 11 EliteLearning.com/Nursing
Book Code: ANCCNC3022C
soybean oils. Flaxseed oil is a good vegetarian source of ALA, Evidence-based practice! Calder (2015) acknowledged that
but its use in the common American diet is limited. EPA and inflammation contributes to the pathology of various disease
DHA can be generated in the body through ALA conversion, states and that EPA and DHA, found in fish oil supplements,
but this source too is limited. The best source of EPA and DHA are able to partially blunt this condition through a number of
is fatty fish such as salmon, trout, and tuna, as well as shellfish distinct mechanisms. Further, he stated that both substances
such as crab, oysters, and mussels. In addition to these sources, facilitate the generation of mediators that work to resolve
omega-3 fatty acids are widely available as dietary supplements. inflammation through multiple linked biochemical mechanisms.
Although vegetarians may consider flaxseed and algae oils as Unfortunately, not all of these processes are fully understood.
supplemental sources of EPA and DHA, respectively, fish oil- He goes on to note that animal research in models of
rheumatoid arthritis (RA), inflammatory bowel disease (IBD),
based supplements are a common source of all three fatty acids and asthma respond to treatment with omega-3 fatty acids. In
(National Center for Complementary and Integrative Health humans, though benefit has been shown in the treatment of
[NCCIH], 2018). RA, clinical trials of fish oil in the treatment of IBD and asthma
It is well acknowledged that omega-3 fatty acids are critical to are inconsistent and unable to show any evidence of efficacy.
facilitate a variety of functions, including the activity of muscles,
clotting of blood, cell division/growth, and fertility. More NCCIH’s opinion aligns with Calder’s findings and comments on
specifically, DHA is needed to support brain development and other potential indications (NCCIH, 2018):
function. ALA is considered “essential,” meaning that there is ● Fish oil may be useful to relieve symptoms of rheumatoid
no way for the body to make it; it must be obtained from either arthritis.
food or dietary supplementation. Perhaps because of the many ● Omega-3 supplements have not been shown to reduce the
potential health benefits of omega-3 fatty acids, research has risk of heart disease. People who consume seafood regularly
been conducted examining their role in a variety of pathologies. are less likely to die of heart disease.
Examples evaluated include conditions affecting the circulatory ● High-dose omega-3 supplementation may reduce
system, brain, nervous system, mental health, the eye, triglyceride levels (included as an indication for prescription-
rheumatoid arthritis, and infant development (NCCIH, 2018). only fish oil products).
● Omega-3s have not been convincingly shown to be
The 2012 National Health Interview survey showed that fish beneficial in the treatment of age-related macular
oil supplements are the most commonly used nonvitamin and degeneration and many other conditions (NCCIH, 2018).
nonmineral natural products consumed by American adults and
children. This survey indicated that nearly 8% of adults had used When used as directed, fish oil supplements are typically
a fish oil supplement in the previous 30 days (NCCIH, 2018). considered to be safe and well tolerated. Nonetheless,
belching, bad breath, heartburn, nausea, loose stools, rash, and
Nursing consideration: There appears to be reasonable nosebleeds have been associated with their use. Further, at high-
evidence that eating seafood confers some health benefits. dose levels, fish oil may increase the risk of bleeding and stroke.
It is not clear, based on research conducted to date, that all Lastly, it is unclear if people with allergies to fish or shellfish can
of these same benefits can be obtained by consuming fish oil safely use fish oil (Mayo Clinic, 2017b).
supplements. As a result, nurses should discuss these potential
differences with their patients. In any case, all patients will
benefit with a shift to more healthy eating habits.
Case study 4
In preparation for Steve’s appointment with his APN, he is
completing a medication history with Nurse Jill. In the past, he Self-Assessment Quiz Question #10
has been taking a prescription omega-3 ethyl ester supplement
Steve appreciated Jill’s sharing information on the proper
(Lovaza) to help reduce his chances of suffering heart disease.
use of fish oil and wanted to consider using an OTC fish oil
Unfortunately, as a result of the COVID-19 pandemic, Steve
product in an effort to bring down his triglycerides. This might
has lost his job and is unable to afford COBRA health insurance
be effective, and it might be less expensive than paying cash
and its pharmaceutical benefit. He was happy with how Lovaza
for a prescription product. Nonetheless, before taking this
was working for him and asks Jill if she can suggest a less
to his APN, he asks Jill what he might expect as far as side
expensive alternative. His clinical laboratory results indicate a
effects. He had experienced fatigue when taking Lovaza and
total cholesterol level of 220 mg/dL, LDL-cholesterol of 80 mg/
wanted to know if he should expect this to continue. Which of
dL, and a triglyceride level of 612 mg/dL. He is not taking any
the following adverse events is known to be associated with
other medications other than a daily multivitamin and suffers no
the use of fish oil supplements?
outward medical conditions. a. Nausea.
b. Heart palpitations.
Self-Assessment Quiz Question #9 c. Unexplained weight loss.
d. Alopecia.
Identify the parts of Jill’s potential response to Steve that are
factually correct based on currently accepted use guidelines
for fish oil:
a. She recommends an over the counter (OTC) fish oil product
with a high concentration of omega-3 that is verified by the
United States Pharmacopeia (USP) to help prevent heart
disease.
b. She reviews with Steve the approved indications for Lovaza,
noting that it is not indicated for prevention of heart disease
and that there is not sufficient data to support this use.
c. Jill notes that his triglyceride levels are greater than 500 mg/
dL, indicating that fish oil may be appropriate to treat that
abnormality.
d. Both b and c.
Conclusion
The National Center for Complementary and Integrative Health risks. Further, the majority of supplements have not been
has issued several themes that summarize the material presented adequately evaluated for safety in children or women who
in this educational program (NCCIH, 2019): are pregnant or breastfeeding.
● Dietary supplements contain many ingredients. Although ● Although FDA does provide some oversight of dietary
solid clinical research has confirmed the value of some, supplements, the regulations are generally less rigorous than
others remain unproven. those used for prescription or over-the-counter medications.
● The safe use of supplements requires that users carefully read
the labels’ directions. It is also important to recognize that Nursing consideration: The combination of dietary
claims of natural sources do not always translate to safety. supplements’ sometimes unknown pharmacology and safety
This is especially true in the case of herbal/botanical products liabilities may complicate the provision of healthcare, especially
that may contain multiple ingredients – some unknown. in pharmacotherapy. As a result, it is critical that nurses work
● Supplement-food and supplement-drug interactions are with the healthcare team to obtain comprehensive medication
always a possibility; some interactions pose significant histories to include dietary supplements.
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20364810 medicalnewstoday.com/articles/161618
Mayo Clinic. (2017c). St. John's wort. https://www.mayoclinic.org/drugs-supplements-st- Weatherspoon, D. (2019). Potassium. https://www.healthline.com/health/potassium
johns-wort/art-20362212 WebMD. (n.d.a.). Cannabidiol (CBD). https://www.webmd.com/vitamins/ai/
Mayo Clinic. (2017d). Vitamin A. https://www.mayoclinic.org/drugs-supplements-vitamin-a/ ingredientmono-1439/cannabidiol-cbd
art-20365945 WebMD. (n.d.b.). Chromium. https://www.webmd.com/digestive-disorders/tc/chromium-
MedlinePlus. (2019). Magnesium in diet. https://medlineplus.gov/ency/article/002423.htm topic-overview#1
MedlinePlus. (2020a.) Copper in diet. https://medlineplus.gov/ency/article/002419.htm WebMD. (n.d.c.). Nickel. https://www.webmd.com/vitamins/ai/ingredientmono-1223/nickel
MedlinePlus. (2020b). Sodium. https://medlineplus.gov/sodium.html WebMD. (n.d.d.). Vitamin B12. https://www.webmd.com/vitamins/ai/ingredientmono-926/
MedlinePlus. (2020c). Vitamins. https://medlineplus.gov/ency/article/002399.htm vitamin-b12
Memorial Sloan Kettering Cancer Center. (2019). Pomegranate. https://www.mskcc.org/ WebMD. (2020a). Are there health benefits to drinking pomegranate juice? https://www.
cancer-care/integrative-medicine/herbs/pomegranate webmd.com/diet/health-benefits-pomegranate-juice#1
Mister, S. (2020). A mandatory dietary supplement registry: Transparency as “disinfectant.” WebMD. (2020b). Phosphorus in your diet. https://www.webmd.com/vitamins-and-
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supplement-registry-transparen WebMD (2020c). Probiotics – Topic overview. https://www.webmd.com/digestive-disorders/
Multum, C. (2019). Turmeric. https://www.drugs.com/mtm/turmeric.html tc/probiotics-topic-overview
National Academies of Sciences, Engineering, and Medicine. (2018). Food and Nutrition Wolfe, R.R. (2017). Branched-chain amino acids and muscle protein synthesis in humans:
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boards/food-and-nutrition-board.aspx org/10.1186/s12970-017-0184-9
AN OVERVIEW OF DIETARY SUPPLEMENTS FOR NURSES
Self-Assessment Answers and Rationales
1. The correct answer is A. 6. The correct answer is A.
Rationale: Vitamin B12 deficiencies are sometimes associated Rationale: All of the vitamins used to make MegaRed are
with pernicious anemia. Many times, people with this condition readily available at relatively low cost. The manufacturer of
are unable to properly form red blood cells, and those that this product has developed a proprietary formulation with
they do make may not function properly. desirable, but questionable, utility. Although the product
likely does not intrinsically command such a cost, it seems
2. The correct answer is D.
possible that the manufacturer is creating an illusion of value
Rationale: It is important to know that diagnostic reference
by demanding an exorbitant cost. Gerri, on a student budget,
ranges are designed to represent normal for most people.
could likely procure similar amounts of each ingredient
As such, it is always possible that some individuals may not
individually at a lower total cost.
fall within those standards. Because of this, clinicians must
always rely on their experience and discretion, even in cases 7. The correct answer is C.
where the diagnostic data do not exactly align with what is Rationale: St. John’s wort contains drug-like, pharmacologically
expected. Secondly, it is important to acknowledge the amount active substances. As such, it should be afforded the
of subjectivity involved in patient care. As a result, it may make same consideration as prescription medications. Like most
sense to get a second opinion, especially in cases where the medications, the occurrence of adverse events has been
consequences of a misdiagnosis are great. associated with the use of St. John’s wort.
3. The correct answer is D. 8. The correct answer is B.
Rationale: MegaRed, when taken at a maintenance dose of two Rationale: St. John’s wort is known to sometimes interact with
to three tablets per day, is formulated to provide more than is anticoagulant medications such as clopidogrel.
needed to meet the nutritional needs of 97% to 98% of healthy 9. The correct answer is D.
adults for niacin, vitamin B6, and vitamin C. If two tablets are Rationale: Although fish oil has historically been used for the
taken, it would provide 66% of the daily suggested vitamin A prevention of heart disease, this indication is not supported
intake; three tablets would give 99%. by current clinical guidelines and is not an approved use of
4. The correct answer is C. prescription fish oil products. Nonetheless, fish oil has been
Rationale: Vitamin A is a fat-soluble vitamin. As a result, in shown effective in the treatment of triglyceridemia and is
cases where excess is ingested, it is typically stored in fat cells, indicated as such in the package insert for Lovaza.
allowing potentially dangerous accumulation. 10. The correct answer is A.
5. The correct answer is C. Rationale: The most frequently reported adverse events
Rationale: There is no compelling data to suggest that taking associated with the use of fish oil are belching, bad breath,
large doses of vitamin C will prevent a person from catching a heartburn, nausea, loose stools, rash, and nosebleeds. At very
cold. Nonetheless, some studies have provided evidence that high doses, fish oil can lead to bleeding or the occurrence of
vitamin C may be able to reduce the duration and severity of a stroke.
cold.
Course Code: ANCCNC03DS22
Cultural Humility for Healthcare Professionals
3 Contact Hours
Release Date: October 27, 2021 Expiration Date: October 27, 2024
Faculty
Adrianne E. Avillion, D.Ed, RN, is an accomplished nursing continuing education for healthcare professionals and consulting
professional development specialist and healthcare author. services in nursing professional development.
She earned a doctoral degree in adult education and an MS in Adrianne E. Avillion has disclosed that she has no significant
nursing from Penn State University, and a BSN from Bloomsburg financial or other conflicts of interest pertaining to this course.
University. Dr. Avillion has held a variety of nursing positions as Content Reviewer: Mary C. Ross, PhD, RN, is an experienced
a staff nurse in critical care, physical medicine, and rehabilitation nursing educator with extensive clinical experience in multiple
settings, as well as numerous leadership roles in professional areas of nursing including community and mental health. She is
development. She has published extensively and is a frequent a retired Air Force flight nurse and previous chair of a national
presenter at conferences and conventions devoted to the Veterans Administration advisory council. She has extensive
specialty of continuing education and nursing professional experience living and working in foreign countries and with
development. Dr. Avillion owns and is the CEO of Strategic diverse patient populations.
Nursing Professional Development, a business that specializes in Mary Ross has disclosed that she has no significant financial
or other conflicts of interest pertaining to this course.
Course overview
The purpose of this education program is to present an professionals to use when working with diverse patients in a
introduction to cultural humility and offers tools for healthcare culturally humble manner.
Learning objectives
Upon completion of this course, the learner should be able to: Explain cultural humility from the perspectives of oppression,
Define cultural humility. privilege, and marginalization.
Describe dimensions of diversity in the United States. Describe the process of providing patient care with cultural
Identify factors that can interfere in the healthcare humility.
professional/patient relationship with patients of diverse Differentiate between multicultural competency and cultural
cultural backgrounds. humility.
● Complete the self-assessment quiz questions which are at ○ An affirmation that you have completed the
the end of the course or integrated throughout the course. educational activity.
These questions are NOT GRADED. The correct answer is ○ A mandatory test (a passing score of 70 percent is
shown after you answer the question. If the incorrect answer required). Test questions link content to learning
is selected, the rationale for the correct answer is provided. objectives as a method to enhance individualized
These questions help to affirm what you have learned from learning and material retention.
the course. ● If requested, provide required personal information and
payment information.
● Complete the MANDATORY Course Evaluation.
CE Broker reporting
31, 2024); California Board of Vocational Nursing and Psychiatric the Massachusetts States Board’s regulatory requirements as
Technicians (LVN Provider # V15058, PT Provider #15020; valid defined in 244 CMR5.00: Continuing Education. This CE program
through December 31, 2023); District of Columbia Board of satisfies the Massachusetts States Board’s regulatory requirements
Nursing, Provider #50-4007; Florida Board of Nursing, Provider as defined in 244 CMR5.00: Continuing Education.
Activity director
Shirley Aycock, DNP, RN, Executive Director of Quality and Accreditation
Disclosures
course activity.
Disclaimer
Course verification
DEFINITION OF CULTURAL HUMILITY
In the context of healthcare services cultural humility is defined important that healthcare professionals nurture an appreciation
as “a process of being aware of how people’s culture can impact for the many facets of each patient, including culture, gender,
their health behaviors and, in turn, using this awareness to race, ethnicity, religion, sexual identity, and lifestyle. According
cultivate sensitive approaches in treating patients” (Prasad et al., to Yancu (2017), healthcare professionals need both process
2016). In contrast, cultural competency is described as ensuring (cultural humility) and product (cultural competence) to
that healthcare professionals learn a quantifiable set of attitudes effectively provide care and interact with a culturally diverse
that allow them to work effectively within the cultural context of society.
each patient. There is an end point to cultural competency. It
ends with the termination of the healthcare professional-patient Healthcare Professional Consideration: A culturally humble
relationship. On the other hand, cultural humility is an ongoing healthcare professional needs to be able to provide services
process, which requires continual self-reflection and self-critique. that transcend culture, ability, LGBTQ status, and class, as
Cultural humility is a prerequisite to cultural competency. It forms well as integrate healthcare professional-stated cultural and
a basis for effective, harmonious healthcare professional-patient other considerations into treatment. Moreover, the healthcare
relationships (Prasad, 2016). professional must recognize the roles that power, privilege,
Cultural humility involves entering into a professional relationship and oppression play in both the counseling relationship and
with a patient by honoring the patient’s beliefs, customs, and the experiences of patients (Sue & Sue, 2021).
values. Cultural competency is described as a skill that can
be taught, trained, and achieved. This approach is based Self-Assessment Quiz Question #1
on the concept that the greater the knowledge a healthcare
professional has about another culture, the greater the Which of the following statements pertains to the definition of
competence in practice. Cultural humility de-emphasizes cultural cultural humility?
knowledge and competency and focuses on lifelong nurturing a. Healthcare professionals must learn a quantifiable set of
of self-reflection and self-critique, promotion of interpersonal attitudes.
sensitivity, addressing power imbalances, and promoting the b. Cultural humility is an ongoing process.
appreciation of intracultural variation and individuality (Stubbe, c. Cultural humility is a skill that can be taught.
2020). This humility exemplifies respect for human dignity. d. Healthcare professionals know that there is an end point to
An important part of cultural humility is identifying one’s own cultural humility.
biases, self-understanding, and interpersonal sensitivity. It is
DIMENSIONS OF DIVERSITY IN THE UNITED STATES
Definitions
Diversity is a multidimensional concept that refers to many [LGBQ]), gender identification (i.e., identifying as transgender),
aspects of an individual that combine to comprise an overall and disability. Although this is not an exhaustive list of all
sense of self. Moreover, diversity occurs within a cultural and elements of individual diversity, it does address many prominent
social context where variances within the general population are dimensions of diversity an individual may have as well as
treated differentially based on the social, political, and cultural determine where that individual falls within the societal hierarchy.
constructs existing within a society. Some dimensions of diversity Dimensions of diversity also serve to privilege and empower
include race, socioeconomic class, gender, sexual orientation some members of society while oppressing and marginalizing
(i.e., identifying as lesbian, gay, bisexual, queer/questioning other members of society (Sue & Sue, 2021).
Intersectionality is a concept that is used to describe how these is often oppressed and marginalized because of her race and
various dimensions come together to privilege or oppress gender; however, as a highly educated academic who is not
individuals and groups of individuals. Intersectionality is defined gay, she experiences power and privilege, particularly in the
as “multiple, intersecting identities and ascribed social positions academic classroom setting as the course professor. Another
(e.g., race, gender, sexual identity, class) along with associated example is a female student who has experienced poverty on
power dynamics, as people are at the same time members of and off throughout her life cycle and identifies as biracial and
many different social groups and have unique experiences with gay; she may experience multiple identities that compound her
privilege and disadvantage because of those intersections” oppression and marginalization (i.e., female, poor, gay, biracial).
(Rosenthal, 2016, p. 475). The concept of intersectionality provides a useful framework
Each individual has a multitude of diverse identities; some for healthcare professionals, as it helps them to understand the
are visible and some are not readily identifiable. Each of the complexity of patients’ diverse identities. Further, it provides
identities intersects with the other identities. The multiple a structure for understanding the multitude of factors that
intersections can serve to provide for further oppression and may cause a patient to be oppressed and/or privileged within
marginalization or further power and privilege, and/or they could the context of American society. In this same manner, it is
mitigate one another, providing some facets of privilege and important to recognize that culture is best described as fluid and
others of oppression. For example, an African American college subjective, as will be discussed in greater detail with respect to
professor who is a heterosexual woman with a doctoral degree providing patient care with cultural humility.
Race, ethnicity, and immigration

The United States (US) is a nation of immigrants. The racial, professionals better conceptualize the potential diversity of
ethnic, and immigrant diversity within American society is often experiences among their patients.
cited as one of its greatest strengths. However, it has also been Demographics
a challenge for America and for Americans in terms of fully The US has more immigrants than any other country in the world.
accepting and embracing the broad array of immigrant groups Currently, more than 40 million people living in the US were born
that have become American. Historically, every new immigrant in another country. This figure represents one-fifth of the world’s
group has experienced various degrees of prejudicial and immigrants. Nearly every country in the world is represented
discriminatory treatment and exclusion from mainstream society. among US immigrants (Pew Research Center, 2020b).
However, the experience of many European (e.g., Irish, Italian,
German) immigrants was one of initial discrimination followed by In 2018, there were a record 44.8 million immigrants living in
swift acculturation and assimilation, likely aided by the physical the US. This figure represents 13.7% of the nation’s population.
appearance and language similarities to those of earlier settlers. Since 1965, the number of immigrants living in the US has more
Asian and Latina/o immigrants have experienced prejudicial than quadrupled. Since 1970, the number of immigrants has
treatment, possibly because of readily identifiable physical and nearly tripled (Pew Research Center, 2020a). Table 1 provides a
language differences. Historical evidence of mistreatment is well breakdown of the US foreign-born population by national origin.
documented, with perhaps one of the most egregious examples
Table 1: Foreign-Born Population by Place of Birth 2018
being the internment of Japanese Americans during World War
II (Nagata et al., 2015). Region Number of People Percentage
Although Americans often think of the journey of voluntary Mexico 11,182,111 25%
immigration of the many ethnic groups that come to America
East and Southeast 8,648,525 19.3%
to build a “better” life, the legacy of the forced immigration of Asia
African American slaves is often overlooked. African Americans
endured 250 years of enslavement followed by 60 years of Europe 4,848,270 10.8%
a status of “separate but equal” as well as continuing racist Caribbean 4,463,891 10%
practices in education, housing, health, and criminal justice
system. The systemic and continuous oppression of African South America 3,304,380 7.4%
Americans is a direct legacy of this forced immigration and has Central America 3,590,330 8%
resulted in enduring educational, health, and wealth disparities
(Bunch, 2016). South Asia 3,668 8.2%
“New” immigrants from Afghanistan, Haiti, and other war-torn or Sub-Saharan Africa 2,032,470 4.5%
environmentally impacted countries are experiencing prejudicial Middle East-North 1,784,898 4%
treatment in society and healthcare. The economic and social Africa
burden
of caring for these immigrants, in addition to the typical flow of Canada and Other 827,093 1.8%
North America
immigrant populations, has aroused discriminatory attitudes in
society and even in healthcare professionals that may already be Oceania 246,371 0.6%
stressed by COVID patient care. Central Asia 131,854 0.3%
Healthcare professionals’ understanding of the differential
Total 44,760,622 100%
treatment of current and past immigrant groups based upon
ethnic, racial, religious, and linguistic background is paramount (Based on data from the Pew Research Center [2020a]).
to their understanding of their patients. The way in which Tables 2-4 provides a breakdown of the US population by race.
individuals and groups are treated from a sociopolitical (macro)
level and from a daily individual interactional level (micro)
necessarily affects their views and understanding of the world
in which they live. From a person in environment perspective,
individuals act upon the environment and the environment acts
and reacts to the individual. Thus, while individuals help shape
the environment around them, the environment also shapes the
individual (Hutchison, 2021).
A demographic breakdown of the diversity in the US is
provided in Tables 1 and 2. This breakdown may help healthcare
Evidence-based practice! Data show that the population Table 4: Population by Race Self-Identification Foreign Born
varies significantly by place of birth and race. Healthcare Race Number of People Percentage
professionals must be aware of the populations they serve to
practice cultural humility. White 20,375,810 45.5%
Asian 12,097,155 27%
Table 2: Population by Race Self-Identification 2018 Some Other Race 6,617,226 14.8%
Race Number of People Percentage Black or African 4,270,404 9.5%
White 236,102,692 72.2% American
Black or African 41,683,829 12.7% Native American 198,677 0.4%
American Indian and Alaska
Native
Asian 18,449,856 5.6%
Native Hawaiian 146,444 0.3%
Some Other Race 16,273,008 5% and Other Pacific
Two or More Races 11,224,731 3.4% Islander
Native American 2,826,336 0.9% Two or More Races 460,543 0.2%
Indian and Alaska (Pew Research Center, 2020a)
Native
Native Hawaiian 606,987 0.2% Self-Assessment Quiz Question #2
and other Pacific
Islander In 2018, from which country/region did the highest number of
(Pew Research Center, 2020a) foreign-born people residing in the US come from by place of
birth?
Table 3: Population by Race Self-Identification US Born a. South America.
b. East and Southeast Asia.
Race Number of People Percentage
c. Mexico.
White 215,726,882 76.4% d. Sub-Saharan Africa.
Black or African 37,413,425 13.2% Healthcare professionals must be careful not to make sweeping
American generalizations regarding characteristics or needs of any
Two or More Races 10,169,825 3.6% population. Further, patients are influenced by a variety of
factors including level of acculturation (to be discussed later),
Some Other Race 9,655,701 3.4% immigration experience, experiences with discrimination,
Asian 2,627,659 2.2% and ability to speak English. Therefore, it is imperative for
healthcare professionals to ask patients about their personal
Native American 2,627,659 0.9% experiences and important events in their lives. Some cultural
Indian and Alaska generalizations may help clinicians increase their knowledge of
Native specific cultures and enhance their understanding of a portion
Native Hawaiian 460,543 0.2% of patients’ differing experiences. However, this is not intended
and other Pacific to shift the healthcare professionals focus away from developing
Islander a better understanding of the dynamics of race, immigration,
(Pew Research Center, 2020a) and other facets of diversity within the current social, economic,
and political environment of the United States. Healthcare
professionals are better prepared to both understand and help
their patients if they are able to understand the cultural climate
in which their diverse patients live and that climate’s role in
accommodating or marginalizing them. Moreover, healthcare
professionals will provide better care for their patients if they
develop a better understanding of how they personally are
accommodated and marginalized by American culture. Race,
ethnicity, and immigration status are only a few of the facets of
diversity that affect patients. Other facets of diversity include
socioeconomic status, disability, sexual orientation, religion,
and gender identification. These facets of diversity can serve as
dimensions that marginalize and/or oppress patients as well.
Poverty
Poverty is often a consequence of immigrants who have
fled war zones, disaster areas, and regions of extreme high Evidence-based practice! Research shows that the poverty
unemployment. The official poverty rate in 2020 was 11.4%, rate in the US is increasing. Healthcare professionals must be
up 1% from 2019. This is the first increase in poverty after five aware of data relating to poverty and work to decrease the
consecutive annual declines. In 2020, there were 37.2 million growing problem of poverty.
people in poverty, about 3.3 million more than in 2019 (U.S. Key points of the 2020 income and poverty in the US include the
Census Bureau, 2020). following (U.S. Census Bureau, 2020):
● Between 2019 and 2020, the poverty rate increased for non-
Hispanic Whites and Hispanics. Among non-Hispanic Whites,
8.2% were in poverty in 2020, while Hispanics had a poverty
rate of 17.0%. Among the major racial groups examined in this
report, Blacks had the highest poverty rate (19.5%) but did not
experience a significant change from 2019. The poverty rate for work often have left women behind. Migrating across hundreds of
Asians (8.1%) in 2020 was not statistically different from 2019. miles and difficult terrain is not feasible for women and children.
● Poverty rates for people under the age of 18 increased from Basic information about women in poverty includes the following
14.4% in 2019 to 16.1% in 2020. Poverty rates also increased (Bleiweis et al., 2020):
for people aged 18 to 64 from 9.4% in 2019 to 10.4% in 2020. ● Of the 38.1 million people living in poverty in 2018, 56%, or
The poverty rate for people aged 65 and older was 9.0% in 21.4 million, were women.
2020, not statistically different from 2019. ● Nearly 10 million women live in deep poverty defined as
● Between 2019 and 2020, poverty rates increased for married- falling below 50% of the federal poverty line.
couple families and families with a female householder. The ● The highest rates of poverty are experienced by Native
poverty rate for married-couple families increased from 4.0% in American Indian or Alaska Native (AIAN) women, Black
2019 to 4.7% in 2020. For families with a female householder, women, and Latinas. About one in four AIAN women live in
the poverty rate increased from 22.2% to 23.4%. The poverty poverty. This is the highest rate of poverty among women or
rate for families with a male householder was 11.4% in 2020, men of any racial or ethnic group.
not statistically different from 2019. ● Unmarried mothers have higher rates of poverty then married
Income data from this report include the following information women, with or without children, and unmarried women
(U.S. Census Bureau, 2020): without children. Nearly 25% of unmarried mothers live
● Median household income was $67,521 in 2020, a decrease below the poverty line.
of 2.9% from the 2019 median of $69,560. This is the first ● In 2018, 11.9 million children under the age of 18 lived in
statistically significant decline in median household income poverty. This accounts for 31.1% of those living in poverty.
since 2011. ● Poverty rates for women and men are almost even
● The 2020 real median incomes of family households and throughout childhood. However, the gap grows significantly
nonfamily households decreased 3.2% and 3.1% from their for women ages 18 to 44 (during prime childbearing years)
respective 2019 estimates. and again for women age 75 and older.
● The 2020 real median household incomes of non-Hispanic ● Women with disabilities are more likely to live in poverty than
Whites, Asians, and Hispanics decreased from their 2019 both men with disabilities and persons without disabilities.
medians, while the changes for Black households were not Women with disabilities have a poverty rate of 22.9%,
statistically different. compared to 17.9% for men with disabilities and 11.4% for
● In 2020, real median household incomes decreased 3.2% women without disabilities.
in the Midwest and 2.3% in the South and the West from ● LGBTQ women experience higher rates of poverty than
their 2019 medians. The change for the Northeast was not cisgender (sense of personal identity and gender correspond
statistically significant. with their birth sex) straight women and men because of
the intersections of discrimination based on gender, sexual
Women in Poverty orientation, and gender identity or expression.
More women than men are living in poverty in the US. Men who
have migrated for employment or to avoid conscripted military
Reasons why women live in poverty
The impact of sexism and racism on society limit the Disability
employment opportunities available to women. Some of the Disability may cause, as well as be a consequence of; poverty.
causes of poverty in women include the following issues. People with disabilities must deal with barriers to employment
Wage Gap as well as lower earnings. Only 16.4% of women who have
Based on 2018 data, women working full-time, year-round disabilities were employed in 2018, compared with 60.2%
earn on average 82 cents for every dollar earned by their male without a disability (Bleiweis et al., 2020).
counterparts. This gap continues throughout the lifespan, Domestic Violence
leaving women with fewer resources and savings than men In the US, domestic violence is the cause of women’s losing an
(Bleiweis et al., 2020). average of eight million days of paid work per year. The Violence
Occupational Segregation into Low-Paying Jobs Against Women Act (VAWA) has led to lowered rates of gender-
Women are disproportionately represented in certain based violence in the US thanks to its programs and services.
occupations, especially low-paying jobs. This is due, in part, to Unfortunately, the programs and services of the VAWA are not
the perception of gender roles that assume women’s work is low able to meet ongoing needs of domestic violence survivors
skilled and undervalued. This is especially true for women of without more funding and expansion of resources (Bleiweis et al.,
color (Bleiweis et al., 2020). 2020).
Lack of Work-Family Policies Self-Assessment Quiz Question #3
Issues such as insufficient paid family and medical leave and
earned paid sick leave impact a woman’s ability to manage work Which of the following persons is most likely to live in poverty?
and caregiving. Childcare is expensive and sometimes hard to
a. A woman who self-identifies as Alaska Native.
access. These issues further compound problems associated with
b. A man who is 45 years of age.
work-family challenges. The coronavirus has exacerbated the
c. A married man with two children.
caregiving burden on women because of essential school and
d. An unmarried woman without children.
childcare provider closures, which contributes to higher job loss
among women (Bleiweis et al., 2020).
Disability
Physical, intellectual, mental health, and other long-term frequently alleged discriminatory claim, accounting for 55.8% of
disabilities constitute another facet of diversity within the all charges. Disability (36.1%) was the next most alleged category
United States. According to the Centers for Disease Control and of discrimination, followed by race and sex. The percentage of
Prevention (CDC; 2020), 61 million adults (26% of adults) in the each category decreased or remained stable compared to FY
US live with a disability. 2019 except for claims of retaliation, disability, color, and genetic
According to the Equal Employment Opportunity Commission’s information (EEOC, 2021).
(EEOC; 2021) Enforcement and Litigation Statistics and Agency Table 5 shows the percentage of adults with specific categories
Financial Report for Fiscal Year (FY) 2020, retaliation was the most of disability in the US.
Table 5: Percentage of Adults with Functional Disability ● Two in five adults age 65 years of age and older have a
Types in the US disability.
● One in four women have a disability.
Functional Description Percentage ● Two in five non-Hispanic, Native American Indians/Alaska
Disability Natives have a disability.
Mobility Serious difficulty walking or 13.7%.
climbing stairs. Evidence-based practice! Research shows that adults living
with disabilities are more likely to smoke, have obesity, have
Cognition Serious difficulty 10.8%.
heart disease, and/or diabetes (CDC, 2020). Healthcare
concentrating,
professionals must be alert to the diseases linked to disability.
remembering, or making
These diseases can compound the challenges that people with
decisions.
disabilities face.
Independent Living Difficulty doing errands 6.8%.
alone.
People with disabilities face several barriers to accessing
Hearing Deafness or serious 5.9%. healthcare. These include the following (CDC, 2020):
difficulty hearing. ● One in three persons does not have a primary healthcare
Vision Blindness or serious 4.6%. provider. (Age group: 18-44 years.)
difficulty seeing. ● One in three people has an unmet healthcare need because
of cost in the past year. (Age group: 18-44 years.)
Self-Care Difficulty bathing or 3.7%. ● One in four people did not have a routine check-up in the
dressing. past year. (Age group: 45-64 years.)
(CDC, 2020) Disability often compounds issues of poverty and access that
The CDC (2020) points out that: can lead to an array of health consequences such as substance
abuse, domestic violence, malnutrition, and even chronic mental
health conditions.
Lesbian, gay, bisexual, transgender, queer/questioning population (LGBTQ)
The LGBTQ population is another historically oppressed group ● LGBTQ Americans may have also experienced significant
in the US. Until the 2015 Supreme Court decision legalizing mental health issues that are related to the COVID-19
same-sex marriage, LGBTQ individuals were not able to marry in pandemic.
most states.
There are more than 5.5 million LGBTQ individuals living in Self-Assessment Quiz Question #4
the US. The LGBT community face barriers to fair and equal
All the following statements are accurate EXCEPT:
access to employment, housing, healthcare, and public
accommodation. There are several nondiscrimination laws a. In the US 61 million adults live with a disability.
on federal, state, and local levels that protect people from b. The type of functional disability that has the highest
discrimination based on such factors as age, sex, and national percentage is that of cognition.
origin. However, until 2020, federal law did not protect c. More than half of LGBTQ Americans report hiding a
individuals from discrimination based on sexual orientation or personal relationship.
gender identity (Roebig, 2020). d. Transgender individuals face unique obstacles to accessing
healthcare.
The Center for American Progress conducted a national public
opinion study on the state of the LGBTQ community in 2020. The complexity of individual diversity is inclusive of not just
The survey included interviews with 1,528 self-identified LGBTQ of racial and ethnic identity but also of variables such as
adults ages socioeconomic class, disability, and LGBTQ status. While these
18 and older. The project was funded and operated by the facets of diversity are not exhaustive, they do represent some
National Opinion Research Center (NORC) at the University of important categories of diversity. Healthcare professionals
Chicago (Gruberg et al., 2020). must consider the unique array of diverse identities that
Major findings from the survey include the following are represented within each individual encountered in each
(Gruberg et al., 2020): therapeutic relationship. The complexity embodied within each
● More than one in three LGBTQ Americans faced patient affects the way that the patient understands and views
discrimination of some kind in the past year. the healthcare professional and the professional relationship,
● More than three in five transgender Americans faced just as the complexity of the healthcare provider’s diversity
discrimination of some kind in the past year. dimensions affects the way that the healthcare professional
● Discrimination adversely impacted the mental and economic understands and views each patient. It is impossible to provide
well-being of many LGBTQ Americans, including one in two information that allows healthcare professionals to gain
participants who reported moderate or significant negative knowledge about categories of people and how they behave
psychological impacts. or view the world, because not only is the variation within
● More than half of LGBTQ Americans reported hiding a individual ethnicities and races endless, but the variation within
personal relationship to avoid experiencing discrimination. each individual also is endless. Instead, healthcare professionals
● An estimated 3 in 10 LGBT Americans faced difficulties should aim to understand the societal landscape that privileges
accessing necessary medical care because of cost issues. and oppresses individuals. The experiences of oppression
● Fifteen percent of LGBTQ Americans reported postponing or experienced by various diverse groups are likely to provide them
avoiding medical treatment because of discrimination. with a unique perspective on both the larger society and on the
● Transgender individuals faced unique obstacles to accessing relationship with healthcare professionals.
healthcare, including one in three who had to teach their
physicians about transgender people.
OPPRESSION, PRIVILEGE, AND MARGINALIZATION
Understanding the concepts of oppression, privilege, and the LGBTQ population, persons who are disabled, and the
marginalization is essential for practicing with cultural humility. economically disadvantaged.
There are various aspects of individual identities that oppress or Some experts have identified the following three themes of
privilege people and their marginalization or empowerment. marginalization (Baah et al., 2019):
Oppression can be defined as “unjust or cruel exercise of 1. Creation of Margins: Margins act as barriers and
authority or power” (Merriam-Webster, 2021). A person or connections between a person and the environment.
group that knowingly or unknowingly abuses a specific group. Margins construct physical, emotional, and psychological
Oppression is a pervasive system. It has its foundation in history boundaries that people experience during interactions with
and is maintained via individual and institutional systematic society. Enforcement and maintenance of boundaries divide
discrimination, personal bias, bigotry, and social prejudice. the political and socioeconomic resources in an uneven
Oppression leads to a condition of privilege for the person or fashion. This also facilitates the unbalanced distribution
the group that is the oppressor(s). National Conference for of critical resources such as healthcare (Baah et al., 2019).
Community and Justice (NCCJ; 2021). This illustrates the concept of social determinants of health
Privilege is a central concept within the healthcare professions. (SDH), which is defined as “the circumstances in which
The concept of White privilege and male privilege was clearly people are born, live, work and age and the systems put
articulated and widely disseminated through McIntosh’s work in place to deal with illness” (World Health Organization
in the 1980s. McIntosh articulated White male privilege as [WHO], 2010).
“an invisible package of unearned assets which he can count 2. Living between Cultures: Living between cultures is
on cashing in each day, but about which he was ‘meant’ to another factor that links marginalization to SDH. Although
remain oblivious. White privilege is like an invisible weightless the boundary or margin separates the dominant and
knapsack of special provisions, assurance, tools, maps, guides, peripheralized group, incomplete integration leads to a
codebooks, passports, visas, clothes, compass, emergency person or group that lives between cultures. Incomplete
gear, and blank checks” (McIntosh, 1998, p. 1). Privileging is “a integration creates a situation where a person or group
process where chances or odds of being offered an opportunity relinquishes characteristics of the marginalized group in
are altered or skewed to the advantage of members of certain order to bond with the dominant society, but is unable to
groups” (Minarik, 2017, p. 55). Essentially, privilege functions do so. Examples of living between cultures are the ways of
by providing some groups of individuals (e.g., White, male, life of most immigrants, migrant farm workers, and other
heterosexual, abled, middle class) with preferred treatment vulnerable groups. People living between cultures tend
in the form of special opportunities and advantages, while to live in areas characterized by limited employment and
withholding that preference from other individuals (e.g., African educational opportunities (Baah et al., 2019).
American, female, LGBTQ, disabled). Privilege can include many 3. Creation of Vulnerabilities: Creation of vulnerabilities are
advantages including being given the benefit of the doubt and created by the cumulative impact of the creation margins
feeling a sense of belongingness (Minarik, 2017). Individuals and living between cultures. Vulnerability is defined as a
who are not privileged experience the opposite – such as being state of being exposed to and unprotected from health-
an automatic suspect or having to prove belonging (Minarik, damaging environments (Baah et al., 2019.
2017). Privilege is not a guarantee of success for those groups Marginalized groups often do not receive the same access to
who receive it; however, it is an advantage that other groups do societal resources such as high-quality education, healthcare,
not receive and allows for opportunities that others are denied housing, or equal access to voting as those groups that are not
(Minarik, 2017). A final key aspect regarding privilege is that it marginalized. The marginalization of oppressed groups prevents
is not necessarily visible to those who receive it. The invisibility them from having a voice and helps to sustain the status quo
of privilege is the key component that allows it to continue. in the United States in which White, economically well-off, and
More simply, when those who receive privilege do not recognize able-bodied individuals control access to social, economic, and
it, they are unable to take actions to change it. Once people political power.
become aware of privilege, they choose to use the benefits of
privilege to advocate for marginalized populations. Healthcare Professional Consideration: Healthcare
professionals should recognize the power imbalances that
Self-Assessment Quiz Question #5 result from oppression, privilege, and marginalization and work
to correct the imbalances within the delivery of healthcare
When discussing oppression and privilege, healthcare services and within the broader institutional and societal
professionals should know that: context.
a. Privilege is the commission of an unjust or cruel exercise of
authority or power. Self-Assessment Quiz Question #6
b. Privilege is a guarantee of success for groups receiving it.
c. Oppression’s foundation is in the “me too” movement. When discussing themes related to marginalization, the
d. Oppression leads to a condition of privilege for the person concept of being exposed to and unprotected from health-
or the group that is the oppressor(s). damaging environments is referred to as:
Marginalization is an important concept in the delivery of patient a. Creation of margins.
care. Marginalization is the “act of placing a person or group in b. Living between cultures.
positions of lesser importance, influence, or power” (Dictionary. c. Vulnerability.
com., 2021). Examples of groups that have been, and are being, d. Boundaries.
marginalized include ethnic and racial minorities, immigrants,
PROVIDING PATIENT CARE WITH CULTURAL HUMILITY
The concept of cultural humility was first discussed in the individual’s own with the hopes of better understanding those
medical world to better understand and address health cultures and thus better meeting the needs of different groups
inequities and disparities (Tervalon & Murray-García, 1998). The who enter counseling, cultural humility focuses on the cultural
concept has evolved to include ideas related to the creation of context within America that marginalizes and oppresses some
a broader and more inclusive society. Unlike the concepts of groups of people, while privileging and empowering other
cultural competency and multicultural competency, which focus groups of people (Foronda et al., 2016).
on gaining knowledge about cultural groups differing from the
Attending to diversity
Critical Thinking Exercise Given the vast diversity within the United States, both healthcare
Trinh, a 17-year-old first-generation American of Hmong decent, professionals and counselors must develop cultural humility
is graduating first in her high school class. Her school counselor as they work with individuals whose life experiences vary in
has encouraged her to apply to top-level colleges, several myriad ways based on many intersecting dimensions of diversity.
of which are hours from home. When Trinh asks about some A primary component of cultural humility is self-awareness.
nearby colleges, the counselor simply tells her that they are As a healthcare professional, completely exploring one’s
“well below her abilities,” even though one is highly regarded. own identity is of extreme importance. It is through knowing
She is accepted by the top-level colleges to which she applied, and understanding oneself that counselors and healthcare
including two Ivy League schools. Despite generous financial professionals can uncover their beliefs, values, and, moreover,
aid packages, Trinh does not accept offers from any of these their implicit biases.
schools. Past the deadline to apply to the local 4-year colleges, Implicit bias is defined as an unconscious and unintentional bias
Trinh decides to go to the local community college and live (van Nunspeet et al., 2015). Individuals may not be aware of their
at home. Her counselor tries to persuade Trinh to reconsider implicit biases (Byrne & Tanesini, 2015). These biases are the
one of the Ivy League schools. Trinh tells the counselor that result of combinations of factors including an individual’s early
she needs to stay home to help care for younger siblings and experiences and learned cultural biases. Thus, ongoing critical
translate for her parents during doctors’ visits. The counselor self-reflection that understands the existence of implicit biases
engages Trinh in a role play to help her tell her parents that she within everyone is necessary. Repeated and evolving processes
needs to make her own decisions and go away to college. of self-reflection make healthcare professionals’ implicit biases
Although school counselors do want their students to succeed, explicit and, therefore, subject to examination and change
what underlying values might have clouded the counselor’s (Byrne & Tanesini, 2015). In addition to understanding their own
judgment in working with Trinh? Trinh had given the counselor implicit biases, healthcare professionals, especially those from
signals that she was not ready to move hours away when she dominant societal groups (e.g., White, heterosexual, male), need
asked about local colleges. Perhaps the counselor, working to explore their own racial, ethnic, sexual, and class identity.
from a belief that individualism is preferred, ignored these Individuals from dominant cultural paradigms often consider
clues, hoping not to play into Trinh’s “separation anxiety.” If the themselves without racial, ethnic, sexual, or class identity as
counselor had viewed her client as being both Trinh and her they have privilege; their identities are considered the norm.
family, rather than only a young woman needing to be more However, without deep exploration of intersecting aspects of
independent, she could have worked with the family to make personal diversity, it is difficult to understand oneself and where
a decision that addressed both Trinh’s needs and those of her biases might insert themselves into healthcare professional
family. By ignoring Trinh’s cultural background and her sense of relationships (Fisher-Borne et al., 2015).
responsibility to the family, the counselor could not help in an
informed way.
Self-reflection and self-critique
Self-reflection and self-critique are ongoing, lifelong processes is important for healthcare professionals to be able to self-
that allow healthcare professionals to continually refine their reflect in “real time” as they deal with the variety of situations
understanding of themselves and their actions and reactions encountered in an ever-changing healthcare environment
within counseling contexts and to continually broaden and (Wignall, 2019).
deepen their cultural understanding through introspection Self-critique is the process of critically examining oneself to
(Foronda et al., 2016). Through ongoing self-reflection continually refine their understanding of themselves and their
and critique, the healthcare professional develops a better actions and reactions and to continually broaden and deepen
understanding of the dynamics within and outside the healthcare their cultural understanding through introspection. Self-reflection
arena and of the ways these dynamics affect the patient’s life, and self-critique are best incorporated into practice on a
the healthcare professional’s life, and the interactions between reflexive basis. That is, the ongoing process of self-reflection
healthcare professional and patient. should result in an automatic process or reflection as an integral
Self-reflection is defined as deliberately paying attention to part of practice. (Foronda et al., 2016).
one’s own thoughts, emotions, decisions, and behaviors. It
Respectful partnerships
Developing respectful partnerships is key to providing healthcare as a bisexual Jewish woman, understands subtle racial insults
services with cultural humility and, more generally, to developing from personal experiences. Some healthcare professionals
a relationship within the counseling setting that allows work imply that because they personally do not discriminate against
to begin and to continue in a productive fashion. Respectful oppressed groups, no personal or societal problems exist
partnerships include discussing and addressing such difficult associated with race, class, LGBTQ status, or disability; this
topics and issues as race, socioeconomic class, gender, sexual attitude negates the experience the patients may have in
identity, and disability. These discussions are uncomfortable for the larger society, where they experience various degrees of
many; they bring up feelings, often passionate, associated with marginalization based on their intersecting identities (Minarik,
“isms,” group identification, prejudice, quotas, and affirmative 2017).
action. Yet these differences between healthcare professional Respectful partnerships are developed when the healthcare
and patient are a presence in the room and, when ignored, have professional facilitates a dialogue that illustrates an
the potential to interfere with an honest and open exchange understanding of and attends to the complex dynamics related
(Minarik, 2017). to privilege, oppression, and marginalization present within the
Healthcare professionals often attempt to take the emphasis off patient/healthcare professional relationship and embedded
race, class, gender, and other areas of difference by denying within the larger society. The healthcare professional levels the
the effect these aspects of diversity have on patients (e.g., “The playing field by conveying a respect for the patient and the
only race I know is the human race”), or by trying to show that patient’s lived reality while inviting the patient to enter an equal
they understand the patient’s experience because they, too, partnership with the healthcare professional.
are a member of an oppressed group. For example, the African
American patient may not feel that the healthcare professional,
Healthcare Professional Consideration: The development Self-Assessment Quiz Question #7
of respectful partnerships is ongoing and acknowledges that
the healthcare professional does not know what the patient’s All the following statements concerning self-reflection, self-
identity, life, or struggles look like but is eager to learn critique, and respectful partnerships are true EXCEPT:
from the patient. Further, healthcare professionals who are a. Discussing and addressing topics and issues such as
developing respectful partnerships recognize that they may race and sexual identify may be uncomfortable for many
make mistakes and are open to patient feedback regarding people.
those mistakes. b. Healthcare professionals seldom attempt to take emphasis
off race, gender, and other areas of differences.
c. Self-reflection and self-critique are ongoing, lifelong
processes.
d. Self-reflection should result in an automatic process as an
integral part of practice.
Lifelong learning
The commitment to lifelong learning within the ethical standards learners understand that they will both make mistakes and learn
requires healthcare professionals to participate in activities that from those mistakes because, as healthcare professionals, they
keep them current on issues and interventions within healthcare are in a constant state of becoming. Lifelong learning allows
and that allow them to provide patients with the most appropriate the healthcare professional to integrate shifting paradigms
care and service. Lifelong learning in the context of cultural and embark on continual reflection and reeducation regarding
humility emphasizes the importance of current issues inclusive dominant perspectives on marginalized populations and
of a multicultural perspective that encompass aspects of critical communities (Obiakor & Algozzine, 2016). Finally, it requires that
self-reflection and advocacy involving continued growth and healthcare professionals separate themselves from thinking about
learning. According to Fisher-Borne and colleagues (2015), patients from a deficit perspective and instead think of patients
“Cultural humility considers the fluidity and subjectivity of culture as fellow humans with rich intellectual, cultural, ethnic, and class
and challenges both individuals and institutions to address backgrounds and with a myriad of strengths (Obiakor & Algozzine,
inequalities. 2016). Recognizing and reflecting on one’s own possible biases,
Cultural humility requires self-reflection and taking risks, religious values, and family values may help to limit the influence
discovering new information, and using patients and others of those biases on their patient interactions.
as resources (Obiakor & Algozzine, 2016). Culturally humble
White identity
White identity theory was first developed by Helms in the 1980s
Healthcare Professional Consideration: National surveys
and 1990s as a tool for White healthcare professionals to “create
do not have a historical track record of asking White people
meaning about their identities as Caucasians, particularly in
meaningful questions about their racial identity (Schildkraut,
terms of how they think about, respond to, react to and interact
2017). Healthcare professionals should promote research that
with patients from different racial/ethnic groups” (Chung &
includes questions about racial identity.
Bemak, 2012, p. 67). In other words, the theory’s formation was
based on the idea that White people are so immersed in the
dominant culture that they are unaware of the influence of the Self-Assessment Quiz Question #8
dominant culture’s ethnocentric images and ideals. Being White
makes it easier to assimilate into the dominant culture and to When exploring one’s own beliefs about White identify, it is
partake in unearned privileges many White people enjoy but do important to acknowledge that:
not acknowledge. Most White people perceive themselves as a. Most White people perceive themselves as biased.
unbiased, but such self-perception may truly impede one from b. White identity theory was first developed to discount the
taking responsibility for one’s own prejudices (Sue & Sue, 2016). idea that White identity exists.
White healthcare professionals have a special responsibility c. National surveys often ask White people questions about
to understand their own privileges, biases, racism, and their racial identity.
discrimination so that they may develop a positive relationship d. Being White makes it easier to assimilate into the dominant
within counseling sessions. culture.
Assessment and treatment
It is important for healthcare professionals to approach every stating, “It sounds like you’re furious with the situation that’s
individual patient with a cognizance of the possible various happened; you’re tired of it.” The father was able to calm down
intersecting identities within the patient, but without a at that point, as the White therapist was allowing him to be
stereotype of the patient based on preconceived notions of angry in his presence and was acknowledging that there might
these intersecting identities (e.g., race, ethnicity, LGBTQ status). be a reason for anger. The therapist then asked the father if his
Implementing the practice of cultural humility may flummox disciplining method had anything to do with wanting to protect
healthcare professionals as they approach patients in a clinical his child. The father responded that, yes, he was afraid his child,
setting (Schildkraut, 2017). “a Black kid,” was at risk of going to prison if he was fighting
The following example from Wyatt (n.d.) illuminates some at school. The father did not want that for his child and was
key elements of providing patient care with cultural humility. frightened. By providing room for the father to express his rage
An interracial couple, an African American father and a White and his fear, the therapist was able to make the clinical session
mother, come into therapy because their child was kicked out of more meaningful.
school for fighting and the father was called into child protective Healthcare professionals who practice cultural humility also
services for spanking his child. When they entered the office, recognize that assessment tools and treatment protocols
the father was very angry and the mother was getting extremely may not be appropriate for all patients. Historically, many
upset, trying to calm him down. The White therapist suggested therapeutic strategies employed in patient care were developed
meeting with the father alone first. When he met with the father, without empirically supported research with ethnic minorities
rather than trying to silence his rage, he joined with him by (Sue & Sue, 2016). However, healthcare professionals should
not rely solely on manualized treatment protocols to guide Table 6: Multicultural Perspectives in Providing Healthcare
their interventions, as such an approach can fail to appreciate
patients’ unique experiences and the effect of differing social 1. Provides the opportunity for two persons – from different
environments. Rather, when employing a research-based cultural perspectives – to disagree without one being
right and the other wrong.
therapeutic practice, healthcare professionals should adapt the
2. Tolerates and encourages a diverse and complex
approach in accordance with the patients’ values, experiences, perspective.
and preferences while understanding the influence of the 3. Allows for more than one answer to a problem and for
broader societal context (Jackson, 2015). Through facilitating more than one way to arrive at a solution.
a respectful partnership that allows patients to take the lead in 4. Recognizes that a failure to understand or accept another
narrating their experiences and in identifying personal treatment worldview can have detrimental consequences.
goals, healthcare professionals can create an environment 5. Takes a broad view of culture by recognizing the following
that appreciates patients’ perspectives. Table 6 outlines the variables: ethnographic (ethnicity, race, nationality,
important aspects of the multicultural perspective in clinical religion, language usage, ability, LGBTQ status);
settings. demographic (age, gender, gender identity, place of
The considerations outlined in Table 6 require healthcare residence); status (social, economic, educational factors);
professionals to balance many different facets of patients and affiliations (formal memberships, informal networks).
6. Conceives of culture as complex when we count the
their lived experiences. It is especially important in treatment
hundreds or perhaps even thousands of culturally learned
to adhere to these guidelines, as it sets up a therapeutic identities and affiliations that people assume at one time
environment in which healthcare professional and patients or another.
are equal, while forcing healthcare professionals to consider 7. Conceives of culture as dynamic as one of such culturally
the validity of various worldviews and the structural inequities learned identities replaces another in salience.
that contribute to the problems and issues patients bring into 8. Uses methods and strategies and defines goals
therapeutic relationships. constituent with life expectations and values.
9. Views behaviors as meaningful when they are linked to
culturally-learned expectations and values.
10. Acknowledges as significant within-group differences for
any particular ethnic or nationality group.
11. Recognizes that no one style of counseling – theory of
school – is appropriate for all populations and situations.
12. Recognizes the part that societal structures play in
patient’s lives.
Note. Adapted in part from Gonzale et al., 1994.

Multicultural perspectives in providing healthcare include all
the following EXCEPT:
a. Provides opportunities for two persons from the same
cultural perspective to disagree.
b. Takes a broad view of culture by recognizing variables.
c. Uses methods and strategies and defines goals constituent
with life expectations.
d. Views behaviors as meaningful when they are linked to
culturally learned values.
Healthcare professional roles
Culturally humble healthcare professionals need to work toward social justice perspective requires healthcare professionals
understanding themselves and their patients within the context to assess and intervene with a perspective that balances the
of privilege, oppression, and marginalization. A healthcare individual patient and the system(s) in which the patient is
professional’s work engages patients as equal partners and experiencing difficulties (Sue & Sue, 2016).
addresses social inequalities and injustices on institutional and The healthcare professional can act as advocate and actively
societal levels. The culturally humble healthcare professional speak with and, when necessary, for members of populations
sees their role in the provision of “therapeutic interventions” who are oppressed by the dominant society. These populations
and addresses systems that serve to oppress marginalized are confronted with institutional and societal oppression.
communities to promote optimal well-being for patients, Healthcare professionals can also be effective as “change
communities, and society. The healthcare professional can agents” working to transform oppressive features of the
fulfill many roles. Because multicultural patient care is closely institutional and societal environments. Rather than attributing
linked to the values of social justice, the need for a social justice patient problems to individual deficits, the healthcare
orientation in patient care is apparent (Sue & Sue, 2016). professional works with the patient to identify external
Social justice counseling is defined as “an active philosophy and contributors to the problem and to remediate the consequences
approach aimed at producing conditions that allow for equal of oppression.
access and opportunity; reducing or eliminating disparities in Further, critical self-reflection in the context of cultural
education, health care, employment, and other areas that lower humility includes analysis of power differentials and how those
the quality of life for affected populations; encouraging the differentials may play out on both individual and institutional
healthcare professional to consider micro, mezzo, and macro levels (Fisher-Borne et al., 2015). Practicing with cultural humility
levels in the assessment, diagnosis, and treatment of patient suggests that healthcare professionals go beyond the confines
and patient systems; and broadening the role of the helping of their offices to address differences in power and privilege that
professional to include not only caregiver/patient therapist affect patients in very tangible ways.
but advocate, consultant, psycho-educator, change agent,
community worker, and so on” (Sue & Sue, 2016, p. 134). The
Healthcare professionals need to be self-aware and realize that imbalances rather than just acknowledge they exist.
patients react positively to healthcare professionals who display Cultural humility challenges us to ask difficult questions
personal warmth, authenticity, credibility, and respect and who instead of reducing our clients to a set of norms we have
strive for human connectedness. Practicing with cultural humility learned in a training or course about “difference.” We
provides the following: believe that asking critical questions … challenge our
A promising alternative to cultural competence … as it own practice as well as our organizations and institutions
makes explicit the interaction between the institution and will provide a deeper well from which to approach
and the individual and the presence of systemic power individual and community change and effective long-term
imbalances. It further calls upon practitioners to confront practice (Fisher-Borne et al., 2015, p. 177).
Institutional and societal accountable: Social justice
Healthcare delivery takes place within and reflects the larger ● How do my behaviors within patient interactions actively
culture. Although healthcare delivery can certainly aid in the challenge any power imbalances and involve communities
wellness of patients, it does not occur in a vacuum. Wellness experiencing marginalization?
cannot be achieved when social injustice is present. ● How, as healthcare professionals, do we address in-
Traditionally some healthcare professionals may consider issues equalities?
of social justice outside the realm of their practice; however, if ● How am I extending my responsibility beyond individual
social justice is relegated to a select few, oppression will flourish patients?
and efforts to heal communities will be blocked. The healthcare ● How am I advocating for policy and practice changes at
professional practicing within a social justice framework would institutional, community, state, and national levels?
not locate the problem within the individual but would look to ● What institutional structures are in place that address
the environmental factors that contribute to the actions and inequalities?
reactions of the individual (Sue & Sue, 2016). ● What training and professional development activities are
offered at our institution or in our community that address
Social justice is the view that everyone deserves equal economic, inequalities?
political, and social rights and opportunities. Social justice ● How can we engage our community to make sure its voice is
depends on economic justice. Proponents of social justice heard in this work?
explain that there must be fair and compassionate distribution (Adapted and updated from Fisher-Borne et al., 2015, p. 176).
of economic growth. Social justice requires that all persons be
provided with access to what is good for the person and in These types of questions can provide a starting point for
associations with others. According to the principles of social healthcare professionals to address social injustices. Healthcare
justice, all people have a personal responsibility to work with professionals can use their positions to advocate for changes in
others to design and continually perfect societal institutions for society to promote social justice. Working toward social justice,
both personal and social development (San Diego Foundation, patients are empowered and can help create an environment in
2016). which equal rights, treatment, and opportunity are available to all.
Although there are variations among the definitions of social Self-Assessment Quiz Question #10
justice, there are three factors that are part of all definitions.
These are (San Diego Foundation, 2016): The factors that are common to all definitions of social justice
● Equal rights. include:
● Equal opportunity.
a. White identity.
● Equal treatment.
b. Equal opportunity.
In other words, social justice mandates equal rights and equal c. Equal incomes.
opportunities for everyone. d. Diversity in all groups.
It is imperative that healthcare professionals ask themselves key
questions that facilitate the acquisition of social justice. Examples
of such questions include the following:
DIFFERENCES BETWEEN MULTICULTURAL COMPETENCY AND CULTURAL HUMILITY
Cultural humility is a conceptual framework that was first understood as a White, middle class, able-bodied, straight,
developed and utilized in the field of medicine and nursing in male, and individually responsible for any difficulties they may
the 1990s. Since that time, it has become more widely applied experience. Multicultural patient care delivery and cultural
to all helping professions. The framework is intended to address competency frameworks commonly assume that the healthcare
some of the shortcomings within the cultural competency and professional is White and that patients are the “other” and set
multicultural counseling frameworks. The approach of cultural out to describe what various racial and ethnic groups believe
humility differs from the multicultural competency approach and how they act as a group. On the other hand, a cultural
in that it recognizes that knowledge of different cultural humility framework emphasizes self-understanding as primary to
backgrounds is not sufficient to develop an effective patient/ understanding others. To facilitate self-understanding, cultural
healthcare professional relationship with each individual. The humility encourages ongoing critical self-reflection, asking the
cultural competency and multicultural counseling frameworks are healthcare professionals to delve into their cultural identity
most often criticized for creating a model that serves to “other” and its effect on the delivery of patient care. Cultural humility
ethnic, racial, and various minority groups (Carten, 2016, p. xlii) makes no assumption regarding the healthcare professional’s
while not acknowledging “Whiteness” as an identity and as a identity and especially challenges White practitioners to explore
culture. “Othering” is the term used for the “biased assumptions and understand their “White identity” (Carten, 2016). Table 7
about populations viewed as ‘the other’ at various times in the illustrates the differences between (multi)cultural competence
country’s history” as well as in the present (Carten, 2016, p. xlii). and cultural humility frameworks.
Othering assumes that various oppressed and marginalized
populations are different from the American “norm,” commonly
Table 7: (Multi) Cultural Competence and Cultural Humility
(Multi) Cultural Competence Cultural Humility
Perspectives on Culture ● Acknowledges layers of cultural identity. ● Acknowledges layers of cultural identity.
● Recognizes danger of stereotyping. ● Understands that working with cultural
differences is an ongoing, lifelong process
● Emphasizes understanding self as well as
understanding patients..
Assumptions ● Assumes the problem is a lack of knowledge, ● Assumes an understanding of self,
awareness, and skills to work across lines of communities, and colleagues is needed to
difference. understand patients.
● Individuals and organizations develop the ● Requires humility and a recognition and
values, knowledge, and skills to work across understanding of power imbalances within the
lines of difference. patient-healthcare professionals’ relationship
and in society.
Components ● Knowledge. ● Ongoing critical self-reflection.
● Skills. ● Lifelong learning.
● Values. ● Institutional accountability and change.
● Behaviors. ● Addressing and challenging power imbalances.
Stakeholders ● Practitioner. ● Patient.
● Practitioner.
● Institution.
● Larger community.
Critiques ● Suggests an end point. ● A “young concept”.
● Can lead to stereotyping. ● Empirical data in early stages of development.
● Applied universally rather than based on a ● Conceptual framework still being developed.
specific client’s experience(s).
● Issues of social justice not adequately
addressed.
● Focus on gaining knowledge about specific
cultures.
Note. Adapted from Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From mastery to accountability: Cultural humility as an alternative to cultural
competence. Social Work Education, 34, 165-181.
Although the intent to understand the diversity within the deemed competent (Fisher-Borne et al., 2015). However, culture
United States is meant to be helpful to healthcare professionals, is fluid and ever-changing, with a complex array of interacting
it often leads to strengthening the status quo (i.e., “White” as dimensions. Thus, it is not possible to reach an end point and to
the norm and all other racial and ethnic groups as outside that be deemed competent.
norm). Because of the desire to describe various racial and The final major criticism of multicultural patient care delivery
ethnic norms, multicultural patient care delivery and cultural and cultural competency frameworks is that they do not present
competency frameworks tend to overlook the diversity within a social change/social justice perspective (Fisher-Borne et al.,
ethnic and racial minority groups and within “White” groups 2015). These frameworks assume that the lack of knowledge
(Carten, 2016; Fisher-Borne, 2015). and understanding of oppressed and marginalized groups
The multicultural counseling and cultural competency frameworks is commonly responsible for inadequate and/or ineffective
also tend to neglect the intersecting dimensions of diversity. By healthcare delivery. The frameworks fail to address the power
focusing on ethnic and racial groups, these models neglect the imbalances present in society and its institutions that are
complexity of group and individual identity. Complex identities integral to many challenges and/or issues that patients bring to
include a multitude of dimensions of diversity, such as race, healthcare interactions. Cultural humility requires patient care
ethnicity, socioeconomic class, LGBTQ status, dis/ability, religion, professionals to recognize the power imbalances within the
regionality (e.g., southern, northern, western, eastern regions of healthcare community and in society. Moreover, cultural humility
the United States), age, gender, religion, etc. These dimensions demands that practitioners hold institutions accountable and
of diversity intersect in many ways. The intersectionality of a asks that healthcare professionals work to right social injustices
multitude of dimensions that are oppressed or marginalized on community and national levels to achieve wellness for
identities within one individual may result in experiencing patients that can only be realized through working toward a
much discrimination (Rosenthal, 2016). On the other hand, the more equitable society (Foronda et al., 2016).
intersection of a multitude of dimensions that are privileged within It is important to note that the healthcare professions are
one individual may result in experiencing much opportunity. committed to cultural competency and increasingly understand
Moreover, the intersectionality of dimensions of diversity results in the need to adopt a cultural humility framework as well.
an infinite number of individual identities that are difficult, if not Healthcare professions incorporate cultural competency and
impossible, to categorize (Rosenthal, 2016). cultural humility within their ethical and educational guidelines
Multicultural counseling and cultural competency frameworks for competent practice (APA, 2017; ASCA, 2016; NASW,
have been further criticized for focusing on having healthcare 2021). The professions share some commonalities within their
professionals gain knowledge regarding differing racial and guidelines for culturally sensitive practice. There is a need to
ethnic groups and assuming that there is an end point in cultural continually develop an understanding of the diversity of patients
training, where the healthcare professionals’ competency is and to commit to lifelong learning.
Case study: James Choi
James Choi is a 25-year-old Korean American, a new college he feels that he is not achieving as much as he would like
graduate who recently accepted a job as a fund-raiser at the with his career. James is feeling anxious and has some
Humane Society. He was adopted when he was 8 months old symptoms of depression. His family physician has prescribed an
into a middle-class White family. He seeks therapy because antidepressant and encourages James to participate in mental
health therapy. He is seeing Denise, a clinical psychologist who quickly. She remembers again to be careful not to stereotype.
works in a large mental health counseling practice. Denise is When the session concludes, she asks James to schedule
a 30-year-old White woman. She is a recent graduate who has another session so they can explore his concerns further. James
learned a bit about Asian American culture in her graduate says he will on his way out and thanks Denise for her help. Yet,
coursework. On James’s first visit, Denise asks him what brings he never returns to counseling.
him to counseling. James explains that he is disappointed in Questions
himself for not achieving more in his career. He explains that 1. What are some of the reasons James might not have
he has been feeling anxious and depressed and identifies the pursued further therapy with Denise?
antidepressant that he is taking. Denise nods in understanding 2. How could Denise have prepared differently for her session
and remembers that Asian American families often have with James?
high academic standards and family members have a difficult 3. How might she have applied some of the facets of cultural
time seeking therapy, concerned about losing face. As a humility in her counseling?
result, Denise compliments James on being brave enough to 4. How do you think James thinks the healthcare professional
seek therapy. James seems confused by Denise’s response perceives him? Is it helpful to the therapeutic relationship?
but manages to say thank you. James then proceeds to tell
Denise that his parents encouraged him to seek therapy, This case illustrates how unintentional stereotyping can hinder
as they thought that he was showing signs of depression. the development of a therapeutic relationship. Denise is aware
Denise is surprised that an Asian family would encourage their that she may be stereotyping but is having difficulty changing
son to seek counseling but knows that she may have been her thinking about Asian Americans. James’s experiences in
stereotyping based on his ethnicity. Denise continues with the life are vastly different from what Denise imagines they are,
questions, as she does want to know more about his feelings and thus he feels as if he is not being understood or helped by
regarding not achieving as much as he would like in his career Denise. Denise might be helped by engaging in critical self-
as well as his symptoms of anxiety and depression. She asks reflection after her session with James. She might ask herself
James why he is feeling that he is not achieving as much as he what went wrong. She might further explore her stereotypical
should be. James shrugs and says he thought he would be at reaction to James and how that might have alienated him
a higher position after completing college. Denise knows that rather than engaged him in working with her. Denise might
Asian Americans often expect high achievement from their have had more success if she had questioned him more about
children, so she asks James how his parents feel about his his background and his family and had engaged him as an
success thus far. James surprises her again when he says his expert on his own life as she forged a respectful partnership
parents are extremely proud of him and think he has landed a with him. It seems as if Denise felt she had to be the expert
great first job. Denise is baffled and asks James to share more and display cultural competency, which may have prevented
about his disappointment given his parents’ support and his her from being able to listen to James and discover the unique
success at both graduating from college and getting a job so diversity in his life.
Case study: Linda Rogers

Linda Rogers is a 28-year-old White woman who has two session, Janine again affirms Linda, telling her she is glad that
children, ages seven and three. She and her fiancé live in a she came in and that it is wonderful she will begin smoking-
trailer park in a rural area. She comes into the county mental cessation classes and use her work breaks to decrease her
health clinic because she is experiencing headaches and stress by taking a short walk.
dizziness and often has severe stomachaches. The clinic Linda misses the next several sessions with Janine. She shows
physician suggested Linda make an appointment because, up for a session with Janine several months later. Janine greets
upon examination, she could not find a physical reason for Linda warmly and says she has missed her at her previously
Linda’s headaches and stomach problems. During the intake, scheduled sessions. Janine then asks Linda about her stress
Linda reports that she often skips meals or eats something and her headaches and stomachaches. Linda says she is still
from the vending machine at work for lunch; she also admits very stressed and continues to experience headaches and
to smoking. Linda also reports that she typically feels fine stomachaches. Janine gently asks whether she attended any
and tries to limit her visits to the clinic. When Janine, the smoking-cessation sessions. Linda states that she doesn’t
African American, upper-middle-class mental health nurse have the time or energy to attend the classes. Janine asks
practitioner, asks Linda what she feels her stomachaches are whether Linda has been walking during work breaks. Linda
caused by, Linda seems unsure and on the verge of tears. looks abashed but admits that she is still using breaks to
Janine compliments Linda for coming to therapy and asks smoke. Janine is a bit frustrated and asks Linda what she thinks
her to discuss her problems more fully. Linda states that she they should work on in session today to reduce stress. Linda
has a lot of stress in her life as she has two minimum-wage doesn’t seem to know what to do, so Janine suggests they
jobs and two kids. She states that her fiancé is supportive, try other options to reduce stress. Linda agrees. The rest of
but he experiences a great deal of stress, too. Janine is the session is spent coming up with a detailed plan to reduce
empathetic and agrees that there is a lot of stress in Linda’s stress through breathing exercises and a plan to try to attend
life. Janine asks Linda what she does to reduce stress. Linda smoking-cessation sessions.
states that her breaks at work give her the opportunity to
smoke and that smoking temporarily relieves her stress and When Linda returns to counseling several weeks later, she
her physical symptoms. Janine feels strongly that smoking is again admits to not following through on Janine’s suggestions.
a bad habit, and although it might temporarily relieve stress, She is still stressed. Janine is frustrated at the lack of progress
Linda should attempt healthy stress relief techniques. Linda but continues to try to help Linda with her stress through
nods in agreement but acknowledges it has been difficult to offering a variety of self-care options. Linda continues to agree
quit smoking. Janine asks what Linda likes to do in her free to try a variety of techniques and agrees to continue to meet,
time. Linda states that she does not have much free time but with little enthusiasm.
between work and her kids. Janine asks Linda if she would Questions
like information about a smoking-cessation class offered at 1. What cultural forces might have affected Linda and
the clinic to help her stop smoking. Linda nods and accepts Janine’s interactions?
the pamphlet Janine offers. They spend the rest of the session 2. How might Janine have explored Linda’s stress more
brainstorming about other ways to reduce the stress in Linda’s comprehensively?
life. Linda is engaged in the brainstorming and agrees to try 3. How did the therapy techniques reflect a middle-class
to use her work breaks to walk off her stress. At the end of the perspective?
4. If you were the nurse practitioner, what would you do? luxury of time, and smoking provides her quick relief. Although
Why? Linda may want to stop smoking, it is unlikely that she has the
It is not surprising that Linda sought help from the clinic doctor time to devote to smoking-cessation classes. Janine might
first because her poverty likely afforded her little opportunity to have wanted to work with Linda on some of the stressors in
seek therapy. Fortunately, the clinic she went to had counseling her life that require advocacy outside the office. For example,
services available and Linda was able to meet with a therapist. Linda’s inadequate diet may be the result of not being able to
Although Janine is empathetic and caring, she fails to make afford enough food. Janine could have explored this with Linda
headway with Linda’s stress and is frustrated by Linda’s lack and helped Linda access various governmental and nonprofit
of follow-through. Janine neglects to thoroughly explore the programs to help her obtain sufficient food. Although Linda
role that poverty plays, both in Linda’s stress response and in agreed to continue to work with Janine, she may have done so
her ability to pursue stress reduction in the way that someone because she does not feel that she had an option.
with more resources might be able to. Linda does not have the
Conclusion
When working with patients from diverse backgrounds, partnerships with patients. Moreover, the culturally humble
healthcare professionals must be willing to continuously look at healthcare professional considers how the societal structures
personal dimensions of diversity and at how those dimensions in the United States serve to oppress some individuals and
affect their worldview and their view of their patients. Thus, groups while empowering other individuals and groups.
healthcare professionals enter the professional relationship with Patients are affected by the inequality within the United
a solid base of self-knowledge and a continuous commitment States. They are affected by living in a society where racism,
to critical self-reflection. Healthcare professionals also enter sexism, classism, homophobia, and discrimination based on
into patient interactions with an open mind and curiosity a variety of other diverse identities, including disability and
regarding patient’s lived experience. Healthcare professionals gender identity, are expressed in a multitude of ways; this
do not pretend to know or understand each patient’s unique discrimination obstructs access to resources and opportunities
combination of facets of diversity and do not assume that the and impedes interpersonal relationships. The power imbalances
patient will behave or believe in any way based on those facets within society and institutions and as experienced by patients
of diversity. In fact, the culturally humble healthcare professional require the culturally humble healthcare professional to take
“cultivate(s) openness to the other person by regulating an active role in righting those imbalances. Cultural humility
one’s natural tendency to view one’s beliefs, values, and challenges healthcare professionals to ask difficult questions
worldview as superior, indeed, the culturally humble healthcare and encourages them not to reduce patients to a preconceived
professional strives to cultivate a growing awareness that one is set of cultural norms that have been learned in trainings about
inevitably limited in knowledge and understanding of patients’ diversity and difference (Foronda et al., 2016). Finally, the
backgrounds” (Hook et al., 2016, p. 152). culturally humble healthcare professional will engage in lifelong
This stance of openness and equality provides an environment learning that supports effective practice.
for healthcare professionals to enter respectful and equitable
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CULTURAL HUMILITY FOR HEALTHCARE PROFESSIONALS
1. The correct answer is B. 7. The correct answer is B.

Rationale: Cultural humility is an ongoing process, which Rationale: Healthcare professionals often attempt to take the
requires continual self-reflection and self-critique. Cultural emphasis off race, class, gender, and other areas of difference
humility is a prerequisite to cultural competency. by denying the effect these aspects of diversity have on
patients’ (e.g., “The only race I know is the human race”), or by
2. The correct answer is C.
trying to show that they understand the patient’s experience
Rationale: The highest number of foreign-born people came
because they, too, are a member of an oppressed group.
from Mexico. They represented 25% of the population of
foreign-born people by country of birth residing in the US. 8. The correct answer is D.
There were 11,182,111 people belonging to this group. Rationale: Being White makes it easier to assimilate into the
dominant culture and to partake in unearned privileges many
3. The correct answer is A.
White people enjoy but do not acknowledge.
Rationale: The highest poverty rates are experienced by Native
American Indians, Alaska Natives, Black women, and Latinas. 9. The correct answer is A.
About one in four Alaska Native women live in poverty. Rationale: Multicultural perspectives provide the opportunity
for two persons – from different cultural perspectives – to
4. The correct answer is B.
disagree without one being right and the other wrong.
Rationale: The type of functional disability that has the highest
percentage is mobility. The percentage of people with mobility 10. The correct answer is B.
disability is 13.7%. Rationale: Although there are variations among the definitions
of social justice, there are three factors that are part of all
definitions. These are equal rights, equal opportunity, and
Rationale: Oppression is a pervasive system. It has its
equal treatment. In other words, social justice mandates equal
foundation in history and is maintained via individual and
rights and equal opportunities for all.
institutional systematic discrimination, personal bias, bigotry,
and social prejudice. Oppression leads to a condition of
privilege for the person or the group that is the oppressor(s).
Rationale: Creation of vulnerabilities are created by the
cumulative impact of the creation margins and living between
cultures. Vulnerability is defined as a state of being exposed to
and unprotected from health-damaging environments.
Course Code: ANCCNC03CH
:Fundamentals of Telehealth: Registered Nursing
Practice in the Virtual Care Environment
4 Contact Hours
Release Date: May 13, 2020 Expiration Date: May 13, 2023
Faculty
Author: Patty Alane Schweickert, DNP, FNP-C (eBACKPAC). She was the Program Director of APN PLACE from
Dr. Schweickert, is an experienced Nurse Practitioner at the 2015–2018. Currently she is on the clinical faculty at the UVA
University of Virginia (UVA) and General Faculty in the UVA School of Nursing where she teaches telehealth. She is also a
School of Medicine. She has a diverse foundation for telehealth contributing faculty member at the Walden University College
practice and education with over 32 years of experience in a of Health Sciences DNP Program and part of the adjunct faculty
variety of nursing arenas including nursing education and clinical at the ODU College of Health Sciences, where she collaborates
telehealth. Dr. Schweickert is a doctorally prepared nurse with with colleagues to promote and teach telehealth nursing. She
a BSN, an MSN in Critical Care Nursing, a Post-Masters Primary was a member of the National Organization of Nurse Practitioner
Care Family Nurse Practitioner Certification, and a Doctorate Faculties (NONPF) work group that developed the position
of Nursing Practice (DNP). She was a student member of the paper on telehealth for nurse practitioner education. She is
American Telemedicine Association Board of Directors from a co-editor on an upcoming advanced practice nursing book
2010–2012 and was presented with the American Telemedicine on telehealth (expected July 2020). She is also a published
Association Student Paper Award in 2011 for her work in researcher in nursing telehealth education, telehealth stroke
tele-education. Since graduating with a DNP in 2011, she has education, neuroradiology, and a variety of nursing topics.
focused on educating nurses in telehealth and has developed Reviewer: Susan Rubin, MSN, RN
telehealth programs to address rural health care needs. Dr. Susan Rubin, MSN, RN, received her baccalaureate degree in
Schweickert and her team received a Health Resources and nursing from West Chester University and a master’s degree in
Services Administration (HRSA) Grant Award in 2015 for a clinical trials nursing from Drexel University. She is a published
nursing preceptor education program titled: Advanced Practice author who has experience as a progressive care unit nurse with
Nurse Preceptor Link and Clinical Education (APN PLACE), and a special interest in cardiac nursing.
a 2016 HRSA Grant Award for a School Telehealth Program
titled: Better Health Care for Kids, Parents, and Communities
● Read the entire course online or in print which requires a ○ An affirmation that you have completed the educational
4-hour commitment of time. activity
● Complete the self-assessment quiz questions which are at ○ A mandatory test (a passing score of 70 percent is
the end of the course or integrated throughout the course. required). Test questions link content to learning
These questions are NOT GRADED. The correct answer is objectives as a method to enhance individualized
shown after you answer the question. If the incorrect answer learning and material retention.
is selected, the rationale for the correct answer is provided. ● If requested, provide required personal information and
These questions help to affirm what you have learned from payment information.
the course. ● Complete the MANDATORY Course Evaluation
● Depending on your state requirements you will then be ● Print your Certificate of Completion.
asked to complete either:
CE Broker reporting
Colibri Healthcare, LLC is accredited as a provider of nursing Center’s Commission on Accreditation.
Credentialing
Activity director
June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner
Disclosures
course activity.
Disclaimer
education purposes only and is not meant to substitute for the medical condition
Course verification
All individuals involved have disclosed that they have no No. 241, every reasonable effort has been made to ensure that
significant financial or other conflicts of interest pertaining to this the content in this course is balanced and unbiased.
course. Likewise, and in compliance with California Assembly Bill
Purpose statement
This course will explore basic telehealth concepts and to the virtual practice environment is essential to preserving
technology applicable to the registered nursing telehealth arena. the art and science of nursing in the virtual care environment.
It will examine the role of the telehealth nurse, paying attention These issues are explored by considering how telehealth nurses
to legal and regulatory concerns, and temporary changes to know nursing, know the patient, and know the technology.
regulations during the COVID-19 Pandemic. It will review how This course concludes with a review of the competencies for
telehealth can be used in disasters, emergencies, epidemics, and nursing telehealth practice so nurses can be knowledgeable and
pandemics. Distinguishing how traditional nursing care translates effective.
Learning objectives
After completing this course, the learner will be able to: Examine application of telehealth in natural disasters,
Characterize basic telehealth concepts including application healthcare emergencies/crises, and epidemics and
to healthcare, barriers and benefits, telehealth programs, and pandemics.
telehealth service delivery systems. Apply legal and regulatory considerations to telehealth
Differentiate between the basic types of telehealth nursing practice.
technologies and their application to practice. Describe how traditional nursing care translates to the virtual
Examine roles of the registered nurse in the virtual care practice environment.
environment. Appraise telehealth competencies for the registered nurse in
the virtual care environment.
INTRODUCTION
Telehealth is changing the ways in which nurses are able to relationship and nursing presence to the virtual environment.
care for patients. Through the use of advanced technologies, Additionally, understanding the telehealth nursing role is
healthcare delivery can transcend geographic boundaries and vital for nurses to develop confidence in using telehealth in
time constraints, creating innovative care paradigms. Telehealth everyday practice. This will allow nurses to improve their ability
can fill the gaps in care including lack of access, high cost of to provide care for patients in the virtual care environment.
care, provider shortages, and geographical barriers (Totten Nursing partnership with technology also requires compliance
et al., 2016). It can be used as a response to an emergent or with existing laws and regulations that guide virtual care, so an
critical need for care, such as with the COVID-19 Pandemic, understanding of the issues that surround telehealth will ensure
as it provides ways for providers to care for patients at a patient privacy and data security. Additionally, during epidemics
distance. Nurses are a significant part of the healthcare team, and pandemics, it is important to be aware of changes to rules
having an important role in caring for patients. Telehealth is a and regulations guiding telehealth practice so that nurses can
tool for delivery of nursing care and an important part of the fully support patient care remotely during a national emergency.
future of healthcare. Therefore, proficiency and confidence As nurses partner with telehealth, the art and science of
using telehealth in nursing care is essential. Nurses need an nursing practice will be translated to the virtual environment.
understanding of the technology itself and the technology It is, therefore, essential that nurses gain telehealth nursing
as a tool in nursing care delivery. This will allow nurses to knowledge and understand their role in this new paradigm to
gain perspective and skills in translating the caring nursing continue to be a significant healthcare asset.
FUNDAMENTALS OF TELEHEALTH: REGISTERED NURSING PRACTICE IN THE VIRTUAL CARE

ENVIRONMENT CONCEPTUALIZING TELEHEALTH
“Telehealth nursing is a concept. The concept is of imparting know the family and circumstances in this case study. The case
nursing presence and relationships using technologies to study family lives in a very remote, rural part of the country,
improve health” (Schweickert & Rutledge, 2020). where healthcare disparities are prevalent. The average age of
This course will present case studies to enable application of the people in this county is 65. It is considered to be a Health
the concepts to nursing practice. Let’s begin by getting to Professional Shortage Area (HPSA), which indicates geographic,
population, or facility shortages, especially for primary care, The family consists of a mother, Ellie, who is 38 and works as
dental, or mental health services (HRSA Health Workforce, n.d.). a registered nurse in a primary care clinic an hour away from
Overall population health is low, as economic conditions from home. She is in generally good health despite having diabetes.
this geographic coalfield area contribute to poverty levels that The father, Sonny, is 44 and on disability for emphysema, having
are higher than the state average. It is considered to be in the smoked since he was 12 and worked in the coalfields since he
“stroke belt” and “diabetes belt” of our country, which are was 17. His health concerns include smoking, hypertension,
areas that have higher than national averages of these diseases emphysema, and renal disease. They have two children: a
(Ingram et al., 2015; Lòpez-DeFede & Stewart, 2019). Chronic sixteen16-year-old daughter (Rowe) and a 17-year-old son
diseases, smoking, and sedentary lifestyles have negatively (Mel) who is a high school senior. They both attend the county
affected the population’s health. Education quality via the public public school. Rowe has some behavioral health problems and
schools ranks low on a state average and higher education Mel vapes nicotine, but they are otherwise healthy. This family
opportunities are few. This population obviously faces many receives some of their care at the primary care health clinic in
social and healthcare challenges. which the mother works, supplemented by the local free clinic.
Telehealth and telemedicine defined
What is meant by telehealth and telemedicine? Although consultation, supervision, and information across distance.
there are multiple definitions for the terms telehealth and Telehealth includes such technologies as telephones,
telemedicine, the basic concept involves using advanced facsimile machines, electronic mail systems, and remote
telecommunications for the electronic transfer of healthcare patient monitoring devices, which are used to collect and
information in the provision of healthcare services. In fact, a transmit patient data for monitoring and interpretation”
2007 study found 104 peer-reviewed definitions of telemedicine (CMS, n.d).
(Sood et al., 2014). Additionally, seven different definitions of The World Health Organization defines telehealth as follows:
telehealth were found to be in use across 26 separate United “The delivery of health care services, where distance
States government departments and agencies in 2014 (Doarn is a critical factor, by all healthcare professionals using
& Merrell, 2014). Differences and shared features of these information and communication technologies for the
definitions relate to the specified areas of: exchange of valid information for diagnosis, treatment and
● Application to rural and underserved populations. prevention of disease and injuries, research and evaluation,
● Delivery of healthcare services. and for the continuing education of healthcare providers, all
● Use in education.
in the interests of advancing the health of individuals and
● Use in healthcare administration.
● Descriptions of public health applications. their communities” (WHO, n.d.).
Understanding telehealth and telemedicine comes, in part, While the definitions vary somewhat, the perception and
from understanding the application to healthcare described in descriptions embody the commonality of use of advanced
the various definitions of telehealth and telemedicine. Since telecommunication technology to provide healthcare services at
a common universally accepted definition of telehealth and a geographical distance.
telemedicine does not exist, we will begin by exploring the Let’s consider one additional definition of telehealth and
definitions of telehealth and telemedicine from Health Services telemedicine from the American Telemedicine Association, which
Resources Administration (HRSA), the Centers for Medicare and defines telemedicine as the following:
Medicaid Services (CMS), and the World Health Organization “The use of medical information exchanged from one site to
(WHO) so that a common understanding of the concepts can be another via electronic communications to improve patients’
gained. health status. Closely associated with telemedicine is the
The Health Resources Services Administration defines telehealth term “telehealth,” which is often used to encompass a
as follows: broader definition of remote healthcare that does not always
“The use of electronic information and telecommunications involve clinical services. Videoconferencing, transmission
technologies to support long-distance clinical health of still images, e-health including patient portals, remote
care, patient and professional health-related education, monitoring of vital signs, continuing medical education and
public health and health administration. Technologies nursing call centers are all considered part of telemedicine
include videoconferencing, the internet, store-and-forward and telehealth” (American Telemedicine Association, n.d.).
imaging, streaming media, and terrestrial and wireless Interestingly, this definition specifically mentions nursing call
communications. Telehealth is different from telemedicine centers, as nursing triage centers have been using the telephone
because it refers to a broader scope of remote healthcare to connect with patients for many years. The American
services than telemedicine. While telemedicine refers Association for Ambulatory Nursing (AAAN) has supported
specifically to remote clinical services, telehealth can refer nursing telehealth via telephone triage and has developed
to remote non-clinical services, such as provider training, evidence-based protocols to guide this practice (AAACN, n.d.).
administrative meetings, and continuing medical education, Although use of the telephone is part of telehealth nursing, the
in addition to clinical services” (HRSA, n.d.). reader is referred to the AAAN web site for further information
The Centers for Medicare Services defines telehealth as follows: on telephone call centers and telephone triage. For the purpose
“Telehealth (or telemonitoring) is the use of of this continuing education activity, the focus will be on the use
telecommunications and information technology to provide of advanced telecommunications technology in nursing practice.
access to health assessment, diagnosis, intervention,
Telehealth applied to healthcare
Healthcare has changed over time as it has continually strived to as advanced technologies are a natural connection to so many
meet the healthcare needs of society. Complex and multilayered aspects of our lives, so too are they a natural connection to
issues prevent equal healthcare access, including the high cost of assist in providing and improving healthcare. The impact of
healthcare, the disparities in care related to rurality, and provider technology on healthcare mirrors the impact of technology upon
shortages that create underserved geographical regions. Parallel our everyday lives.
to these longstanding challenges in healthcare is the emergence Telehealth began with the need to communicate over a
of digital technology. Digital technology is commonplace in our geographical distance. Several early ways of communicating
everyday lives, from using the smartphone to communicate, to at a distance included physical transfer of messages from
shopping online, to attending virtual education classes. Just one location to another via runners, use of sounds to convey
messages via horns and drums, or use of visual methods such as our healthcare delivery system. Telehealth enables care to be
fire and smoke signals (Bashshur & Shannon, 2009; Rheuban & delivered virtually anywhere, at any time, where it is needed
Krupinski, 2018). Jumping forward in time to our contemporary and when it is needed. Telehealth can be used to deliver care
electronic age finds developments such as the telegraph, to all patient populations throughout the care continuum, from
telephone, radio, and television, which found their way into primary care to emergency care to management of complex
healthcare to bridge the gap in healthcare communications at a chronic disease. It contributes to improving wellness and can
distance (Rheuban & Krupinski, 2018). The next significant era in impact hospice and end-of-life care. Telehealth is a universal tool
advancing communication at a distance arrived with our present for all health care and healthcare systems.
digital age as society depends more and more on advanced
Nursing Consideration: Telehealth is revolutionizing health
communications using wired and wireless formats. care and how nurses care for patients. It is therefore important
The fundamental issues in healthcare related to lack of access to for nurses to gain knowledge and skills using telehealth as
care and the ability of advanced telecommunication to bridge nurses engage in this new paradigm of care.
this gap have effectively opened the door to a redesign of
BENEFITS AND BARRIERS TO USING TELEHEALTH

Benefits
Telehealth as a tool in healthcare delivery can be used to ● Enables care delivery in virtual clinics via virtual consultations.
positively affect population health by providing access to care. Improved Quality
This can result in improving patient health and outcomes, ● Improves efficiency of care.
improving quality of care, decreasing the cost of care, extending ● Decreases readmissions.
provider capacity, and increasing provider satisfaction and the ● Decreases hospital days.
positive patient care experience. Benefits of telehealth are ● Quicker identification of complications/need for
therefore characterized by benefits to the patient, the provider, management changes.
and the healthcare system through the ability to improve access ● May help with self-care via more frequent management and
to care, improve quality of care, decrease costs, and improve interactions with provider.
satisfaction (AHRC, 2013; AHRQ evidence map, 2020; ATA, ● Allows for more frequent opportunities to provide patient
self-care education.
2015; Bilchick et al., 2018; Kruse et al., 2017).
Decreased Cost of Care
Access to Care ● Decreases cost of care (lower readmits, fewer or less hospital
● Transcends geographic distance, geographic isolation, days, better management of chronic disease).
rugged landscape, and extreme climate. ● Less travel: smaller carbon footprint for healthcare.
● Addresses the unmet needs of providing care. ● Can access care in own home, retain local providers, and
● Addresses unmet needs of specific populations such as engage in mobile clinics, which are timely and effective.
prison inmates and those with mental health disorders. Improved Satisfaction
● Provides specialty care otherwise unavailable. ● Increases patient satisfaction/improves patient care
● Addresses provider shortages. experience.
● Improves provider efficiency. ● Improves traditional care by extending ways dedicated
● Improves provider satisfaction by way of improving patient providers communicate/care for the patient, for example, in
care, ease of communication, decreasing travel, extending the care of infectious isolated patients.
provider capacity.
Barriers
Telehealth is a disruptive technology as it changes the traditional Cost
care model regarding where and how patients can access care. ● The cost of setting up telehealth services is often prohibitive,
With telehealth, patients no longer must travel to the provider especially in rural areas.
to receive care. This transforms the traditional paradigm of ● Rural areas may face difficulty sustaining adequate patient
healthcare delivery and offers a multitude of ways patients can volumes.
access and receive care, affecting every aspect of healthcare Legal and regulatory
in its wake. Of course, as with any change, there are barriers to ● Barriers are present in the laws and regulations guiding
address for success of the transformation. Barriers are related to telehealth practice, including low reimbursement or lack of
technology, cost, laws and regulations, and to attitudes toward reimbursement for certain telehealth services.
telehealth use (Kruse et al., 2016; Weinstein et al., 2014): ● Provider credentialing and licensure restrictions prevent
providers from caring for patients across state lines unless
Technology they are also licensed in that state.
● Limited access to high-speed broadband internet affects Attitudes
patients’ ability to participate in video consultations, remote ● Lack of trust in use of technology.
home monitoring, or smartphone applications and programs. ● Change in paradigm of traditional care.
● Lack of provider buy-in.
● Lack of patient confidence.
Case study – Phase 1
Consider how people in rural and geographically remote regions journey, they usually stay overnight near the medical center the
receive traditional health care (i.e., local clinics, local health night before and the night after the visit. Ellie drives an older car
departments or free clinics, traveling long distances to larger that also requires regular maintenance to make such a long trip.
clinics or medical centers to receive care or specialty care, Once it broke down on the way and they had to stay in a local
etc.). Then consider how telehealth can improve access to care, shelter until the car was repaired, causing them to miss the clinic
improve care quality, decrease cost of care, and increase the visit. On average, each specialist visit results in three days of
satisfaction of the patient. time and two nights’ cost in a hotel for this family. Also, Ellie has
Sonny, from our case study, has renal disease, which requires him to take off three days of work to accompany her husband for the
to see a specialist every 12 weeks. To see the specialist, he and visit since he cannot drive himself. Although this only occurs four
his wife travel six hours to attend the clinic visit and obtain lab times a year, this trip strains their family budget due to the high
testing. Since it is an early morning appointment and such a long cost of the travel and Ellie’s days of missed work.
TELEHEALTH PROGRAM BASICS
There are a variety of ways of using advanced telecommunication
technologies to connect with patients. Structures of telehealth Self-Assessment Quiz Question #1
programs are diverse, so it is important to review program basics. Which scenario below best illustrates the benefits of telehealth
Central to any telehealth program are patients. The location of as applied to Sonny’s need for specialty care visits?
the patient is designated as the originating site by CMS (n.d.). a. Sonny has unmet care needs so he should work more with
The remote or distant site is where the provider is located when local providers to obtain care, negating the need for long-
delivering telehealth care. The originating site and the remote site distance travel to larger medical centers.
are connected using advanced telecommunications technologies b. Telehealth is an effective way to receive specialty care,
for the purpose of healthcare delivery. These telehealth although the cost is higher as compared to traditional care.
technologies are considered the tool or instrument that assists c. Although telehealth is available for Sonny’s specialty care
and allows the remote provider to engage with the patient
with the care delivery. in real time, it does not enable the provider to receive
Although each program is unique as to target population, any diagnostic or physiologic data remotely, such as renal
goals, technology used, and desired outcomes, there are function tests.
basic components of each program. As a nurse, it is important d. Receiving telehealth care via a remote specialty provider
to understand the basic components so that the telehealth provides Sonny improved access to the care, increases the
nursing role can be realized. A brief overview of a telehealth quality of care he receives, and decreases the cost of his
care, resulting in increased satisfaction with the patient
program begins with a needs assessment and determination care experience.
of the necessary services along with identifying the target
population to be served. Clear identification of the purpose,
goals, program objectives, and desired outcomes is necessary Self-Assessment Quiz Question #2
to align the purpose with intended goals and outcomes. While telehealth is an innovative solution to providing care,
Organizational readiness must also be a component of the early especially to those in rural or remote regions, barriers do exist.
assessment plan so that stakeholder buy-in can be fostered. A Apply your knowledge of barriers to telehealth to choose the
business model to frame the program should be developed and best response that demonstrates these barriers:
supported with funding or other financial support initiatives. a. Sonny’s local facility has high-speed internet capabilities
Next, a detailed plan for the project development with selection and connections to the larger medical center, providing
of the technology to meet the stated outcomes is an essential telehealth specialty consults.
component of any telehealth program. Stakeholders should work b. The local area has limited funds to set up telehealth
systems, especially with the lack of reimbursement for
interprofessionally with clinical experts to gain insight into how certain telehealth services and lack of trust and buy-in from
telehealth technologies work and provide care that results in the providers.
achieving specific healthcare outcomes. Developing summative c. Many of the patients in the local clinic are from across a
and formative program evaluation plans with targeted impact state line as this clinic is on the border between several
analysis of the desired clinical outcomes will enable project states. The local clinic has received a grant to establish
monitoring and substantive evaluation of the project. telehealth, and the nurses and providers in the clinic plan
are licensed in all adjacent states.
Nursing Consideration: Evidenced-based telehealth nursing d. Many of the nurses in the local rural clinic have been
practice is best supported when telehealth best practices and educated in the use of telehealth and have trust in the use
standards of care are integrated into nursing telehealth programs. of technology as a tool in health care delivery.
TELEHEALTH SERVICE DELIVERY SYSTEMS
Telehealth services can be delivered using three main methods. allows providers to monitor patients remotely using a variety of
These include live videoconferencing, store-and-forward technologies and devices. For example, patients can use tablets
technologies, and remote monitoring. Live videoconferencing or have telehealth devices installed in their home to measure
occurs when advanced telecommunications technologies and transmit physiologic data to a distant provider or center to
are used to connect a patient and provider in real time, be monitored for the COVID-19 virus. That data can then be
allowing them to communicate by speaking to one another assessed more frequently than would otherwise be possible with
using computer screens, cameras, computer software, and traditional clinic visits, allowing for more frequent adjustments
the internet. Store-and-forward services enable the transfer in care. Alternatively, patients can use remote monitoring using
of diagnostic imaging and physiologic data from one site to wearable devices, implantable devices, and smartphones.
another. Examples include medical images (such as EKGs, Additional telehealth delivery systems that use the basic
retinal pictures, and pathology slides) or radiology images (such technologies in innovative ways are growing and include mobile
as x-rays, MRI, and CT scans). Physiologic data such as blood health (mHealth), eConsults, and patient education via virtual
pressure, oxygen saturation, weight, and glucose levels are also classrooms.
examples of store-and-forward methods. Remote monitoring
TELEHEALTH TECHNOLOGIES AND APPLICATION TO PRACTICE
Store and forward
A type of technology that gathers data at one site and then Examples of physiologic data includes blood pressure, heart
transmits it to another site is termed store-and-forward rate, temperature, oxygen saturation, weight, sleep quality
technology. Store-and-forward technology is asynchronous, measurements, patient symptomatology measurements and
meaning that the device and patient generating the data do reports, patient self-care education, glucose levels, and EKGs.
not have to be in live communication with the provider or Diagnostic medical imaging transfer using store and forward
receiving site. In this way, physiologic and diagnostic data can includes radiographic images such as MRI, CT, ultrasound, PET
be generated, digitally stored, and then transmitted to the scans, fluoroscopy, mammography, retinal images, dermatology
remote site. Providers can then review the information at their pictures, dental films, and plain x-rays. There are many benefits
convenience. Store-and-forward technology is useful for when to store-and-forward technologies in healthcare. Store-and-
the patient requires an evaluation but does not need to be forward technologies provide time and cost savings for the
present during the data collection and provider review to receive patient, the provider, and the healthcare system (Totten et al.,
2019). They enable the patient to get needed care conveniently,
care. It also enables data to be sent in advance of a patient
the provider to work effectively, and the healthcare system to
consultation or clinic visit to improve care efficiency.
provide better care at a lower cost.
Live videoconferencing
Real-time two-way videoconferencing uses television or computer-based systems, to mobile systems, to more complex
computer screens, cameras, microphones, computers, systems requiring integrated computer networks.
software, and the internet to connect patients and providers
for live engagement. Videoconferencing technologies enable Nursing Consideration: It is important that videoconferencing
simultaneous audio and video transfer in real time between two systems used in healthcare be compliant with Health Insurance
or more sites over the same line, thus creating opportunity for Portability and Accountability Act (HIPAA) and provide secure
the provider and patient to effectively communicate virtually (Liu transmission of data.
et al., 2015). The virtual environment is thus created, allowing
Familiar applications such as Apple FaceTime and Skype are
for care that mirrors traditional care by way of initial consultation
familiar types of videoconferencing platforms but are not
and follow-up visits, assessment, evaluation, care management,
generally HIPAA compliant for use in healthcare. It should be
diagnosis, treatment, and patient education. Unlike store-and-
noted that during the national COVID-19 crisis, rules have been
forward technologies, live videoconferencing is used when live
relaxed to allow use of some non-HIPAA compliant platforms
communication with the patient is required, such as in mental
(CMS, n.d.). Videoconferencing has the immeasurable benefit of
healthcare or in urgent/emergent situations (i.e., acute ischemic
creating the virtual care environment and is an important tool for
stroke). There is a spectrum of videoconferencing systems from
use in providing nursing care virtually.
Remote patient monitoring
The Center for Connected Health Policy defines remote due to the improved access and frequency of care (Vegesna et
monitoring as the use of “digital technologies to collect al., 2017). For example, remote monitoring can transmit daily
medical and other forms of health data from individuals in one vital signs, weight, glucose, oxygen saturation, medication
location and electronically transmit that information securely to administration, and symptoms to the provider. The provider
healthcare providers in a different location for assessment and can then assess the data and data trends and connect with the
recommendations” (CCHP, n.d.). Remote patient monitoring can patient as needed via live videoconferencing to further assess
incorporate both store and forward and live videoconferencing the patient and make changes in treatment and management
into the management of patients through frequent monitoring plans. In this way, integrated (using both asynchronous and
of the patient’s physiologic data and symptomatology. Remote synchronous technologies) remote monitoring programs enable
patient monitoring programs use tablets, mobile devices, patients to be better managed in their homes.
or install equipment into the patient’s home for frequent
assessment of the patient after discharge from the hospital, Evidence-based practice! Research shows that the use of
for improved chronic disease management, or for ongoing remote monitoring results in positive outcomes in chronic
assessment and patient management (Su et al., 2018). Remote disease management (such as in cardiac and respiratory
patient monitoring has the greatest impact on patients with disease), decreased hospital readmissions, decreased
chronic disease, such as those with heart disease and diabetes, mortality, and improved quality of life (AHRQ, 2016).
Mobile health
In our technological society, it is common to access data using their care management, such as in chronic disease management.
mobile devices. Mobile health, or mHealth, is a convenient way Health education can also be enhanced by mHealth, such as
for people to monitor health and access healthcare and health when patients use mobile healthcare applications (apps) to
education. mHealth devices include smartphones, tablets, access healthcare resources or specific healthcare educational
implanted devices, and wearable devices such as the FitBit. information. Medical apps enable transmission of vital signs,
mHealth puts health data in the hands of the user, allowing them glucose, and blood pressure. Additionally, there are apps that
to self-monitor health data and health behaviors. The provider enable the collection of EKGs, ultrasound, otoscopic, and
can also use data from mHealth devices by having the patient ophthalmologic images.
download data to their electronic medical record to assist in
Medical peripherals
Medical peripherals are electronic devices that are used to can use either synchronous or asynchronous technology,
collect physiologic or medical images. They mirror tools used in or both technologies. Commonly used devices include
traditional nursing practice such as the stethoscope, otoscope, digital stethoscopes, wireless scales, dermatology cameras,
and ophthalmoscope. They allow nurses to assess the patient and thermometers. Advanced devices include ultrasound,
in the virtual environment remotely. Medical peripherals colposcope, and retinal cameras.
THE ROLE OF THE REGISTERED NURSE IN THE VIRTUAL CARE ENVIRONMENT
In traditional nursing practice, the registered nurse’s role has nursing care and care delivery and brings a unique opportunity
a wide breath and scope within the healthcare arena. Nurses for additional roles to develop specific to telehealth, such as
are part of the team in virtually every patient care group the telepresenter. Important roles of the telehealth registered
and contribute a wide variety of knowledge and skills to the nurse also include patient educator, the remote monitoring, and
care of the patient. The role of the nurse in traditional care is chronic disease-management. The nursing process is translated
transformed into the telehealth nurse with the use of advanced to the virtual care environment as the telehealth nurse provides
technologies. For example, nurses can apply telehealth to their nursing assessment, diagnosis, goal setting, implementation
nursing role in primary care, specialty care, pre-post follow- of care, and evaluation of outcomes. Following are several
up care, post-hospital discharge care, school nursing, and examples of the nursing role in the virtual environment.
more. Telehealth as a nursing tool allows the nurse to enhance
Ellie’s clinic has received a grant to develop telehealth programs for their patients. When considering the technologies and their
application to practice, it is important that she understand the basic types of technologies and what kind of care each can deliver.
Choose the answer below that best describes a type of technology Ellie could use in a telehealth program.
a. Store-and-forward technology is an asynchronous type of technology that allows data to be collected remotely and forwarded to a
provider. It is used when the patient and provider do not have to be together for the patient to provide the data and then have the
provider review the data.
b. Live videoconferencing is a type of asynchronous technology that enables the patient and provider to communicate in real time.
c. Remote patient monitoring uses only store-and-forward technologies to monitor patients at a distance.
d. Medical peripherals are electronic devices that can collect only physiologic data and enable the nurse to assess the patient in the
virtual care environment.
Telepresenter
The telepresenter plays an important role in telehealth, and information regarding the visit and flow of the visit as well as
the registered nurse is well positioned to fill this role. The answer any questions the patient may have. The telepresenter
telepresenter role emerged around 2000 in an effort to provide nurse educates the patient about telehealth, how to use the
assistance in presenting patients in geographically remote areas telehealth equipment to engage with the provider and to collect
to the remote telehealth physician for patients in geographically physiologic data. Virtual care visits mirror traditional visits and,
remote areas (WSNA, n.d.). A telepresenter in its simplest form is as such, the nurse also opens the medical record and accesses
a healthcare professional who is present with the patient to assist any needed diagnostic testing or imaging within the electronic
the provider in the remote virtual care visit. medical record. Once connected to the remote site, the
The Centers for Medicare and Medicaid Service (CMS) defines telepresenter introduces the patient to the remote provider, and
a telepresenter as “a medical professional at the originating provider to patient. They may present any data that was recently
site that presents a patient to the physician or practitioner at obtained, such as vital signs and history of present illness.
the distant site” (CMS, May16, 2003, p. 5,). The telepresenter The telepresenter assists the remote provider in the evaluation
supports and assists the provider in the clinical evaluation of of the patient, for example assisting with obtaining an otoscopic
the patient as well as facilitates other aspects of the telehealth or oral airway exam. They may assist in obtaining a neurologic
visit, especially related to ensuring effective communication exam by explaining and demonstrating to the patient what the
between the remote provider and patient at the originating site remote provider would like them to do to evaluate a specific
(ATA, n.d.). Telepresenters can assist with patient participation symptom or body area. At the end of the visit, the nurse
in telehealth virtual visits; intensive care nursing, including telepresenter can review the recommended patient medical
those in primary care, acute care, emergent care; and remote management, provide nursing education, and after-visit summary
home monitoring, to name a few. The telepresenter sets up to the patient, as well as schedule any follow-up imaging, labs,
the patient environment at the patient site and ensures the diagnostic testing, or visits.
technology is working. They prepare the patient by way of
Patient educator
All nurses are inherently patient educators and patient education Telehealth enables the nurse to provide patient education
is essential to improving patient health literacy and self-care more frequently and more conveniently. Delivering healthcare
management. Application of telehealth technologies to nursing education can be challenging in geographically remote
care can be successful only when patients embrace the use of regions where chronic disease and healthcare disparities exist,
the technology and are able and willing to participate in care heightening the need for self-care knowledge. High-risk rural
in the virtual environment. Active participation using advanced populations can benefit from tele-education, which nurses are
technology can engage learners. Registered nurses have an in the prime position to provide. Patients who receive education
important role in educating patients about telehealth and also at a distance have shown decreased risk for poor outcomes as it
utilizing telehealth to deliver patient education. Empowering decreases barriers to receiving self-care education. For example,
patients to understand health-related topics and their own health telehealth educational programs for chronic disease have shown
status and management plan is an indispensable component improved outcomes (Rush et al., 2018). Telehealth educational
of the traditional role of the registered nurse. Likewise, patient programs have been found to be feasible and satisfying for the
education is an important role of the telehealth registered nurse. patient, without significant differences between in-person and
telehealth delivery (Warmington et al., 2017).
Nursing Consideration: Patients over the age of 50 likely
need more support and education from care providers to gain
confidence using telehealth (Kurlander et al., 2019). Educating
patients about telehealth is, therefore, an important role of the
telehealth nurse.
Remote patient monitoring nurse
The registered nurse has an important role in remote home is being replaced with smart devices and tablets, apps, and
monitoring. Remote patient monitoring (RPM) is a mode of convenient wearables. Many patient populations can benefit
telehealth that enables nurses to leverage improvements from increased nursing communication and frequency of
in patient health through more frequent nurse-patient monitoring of their condition. These include at-risk populations
communications as well as through more frequent assessment such as those with chronic disease (i.e., diabetes, heart failure,
of the patient’s condition via serial assessment of patient pulmonary disease), post-hospital discharge follow-up (i.e.,
physiological data. Innovation in technology for remote wound care, device use, medication management), and at-risk
patient monitoring is rapidly advancing the possibilities for populations (i.e., elderly/frail patients, COVID-19 patients).
home monitoring of patients as devices are increasing in Nurses using remote monitoring can assess trends in patient
availability, decreasing in cost, and increasing in variety and user physiological and symptom data and enable a timely change
friendliness. For example, better geographic internet coverage in management plans to avoid patient deterioration or
areas enable more patient access to remote monitoring. Bulky complications. In remote patient monitoring, the registered
home monitoring equipment requiring laborious installation nurse has a role in each of the following: program development,
patient initiation, patient education, patient symptom, ○ Connection and collaboration with known provider to
medication, and physiologic data monitoring and management. improve patient trust and comfort in using the telehealth
Program development: program.
● Collaborates with telehealth team. ● Educates patient on the technology and how to use it.
○ Identifies target population. ● Gives input on specific remote monitoring equipment to be
○ Determines needs of the patient. used.
○ Provides input into type of data needed to address goals ● Assesses symptoms, medication, and physiologic data
of program. management goals.
● Educates how to produce the biometric data.
● Educates how to send the data produced.
Patient initiation: ● Educates how the data will be received and assessed.
● Connects with patient regarding the program. ● Educates how the patient will receive feedback and
● Assesses health needs, eligibility, and feasibility of communication for monitoring and health coaching.
participation. ○ Uses motivational interviewing to promote self-care
● Ensures patient consent is obtained. knowledge.
Patient education, patient symptom, medication, and behavior Physiologic data monitoring and management:
modification: ● Assesses patient data and data trends.
● Informs and educates regarding benefits of telehealth RPM. ● Assesses patient condition.
○ Improves the patient’s condition, symptoms, and overall ● Initiates feedback to patients.
health. ● Initiates nursing interventions.
○ Convenience, less driving, and lower cost. ● Initiates changes in patient management via protocols.
Teleprimary care nurse
The nurse’s role in teleprimary care is to be knowledgeable and live videoconferencing in combination with store-and-forward
proficient in the use of technology to deliver teleprimary care technologies, primary care clinics, community-based clinics, and
by translating nursing knowledge and skills from the traditional other ambulatory clinics can connect with patients in real time
primary care arena to the virtual care arena. Teleprimary care to enable better access to primary care and community health
combines primary/preventative healthcare and telehealth services. Patients at these outpatient clinics can connect with
technology to provide, promote, and support access to specialty providers remotely, receiving needed care otherwise
assessment, diagnosis, and treatment of acute and chronic not available in their geographic area. Telehealth registered
illnesses. It supports access to health promotion and health nurses use their existing knowledge, telepresenter skills, and
maintenance care and services. The registered nurse’s role in telehealth nursing competencies to deliver primary nursing care.
teleprimary care mirrors that of the traditional nursing role, The telehealth platform also affords an excellent way for nurses
expanded by the innovative ways the nurse can engage with to deliver patient education, health coaching, and provide
the patient for care delivery using telehealth as a tool. Using follow-up visits.
Telehealth school-based health care nurse
In an effort to decrease absenteeism to improve educational Today, telehealth school-based health centers (tSBHC) offer
success in New York City Schools, Lina Rogers became the resourceful and innovative programs that can offer immediate,
first school nurse in 1902 (Pediatrics, 2016). Her success led to timely, and efficient care for a sick child. When a child is ill,
the development of the school nurse role, instrumental to the this commonly translates to several days of missed classes, a
achievement of students to this day. Since this time, the role of the visit to the local provider, and difficulties with parental work
school nurse has evolved to better meet the needs of school-aged responsibilities when having to take time away from work due to
children. Even today, the role of the school nurse is changing. a sick child. tSBHC improve care and care convenience and have
The traditional nursing role of caring for a sick child in the school been shown to decrease out of workdays for the parent and
nursing office is being revolutionized with technology as the caregiver (Center for Rural Health Innovation, n.d.). Telehealth
school-based telehealth nurse provides access to care otherwise offers cost-effective care for school children in a community-
not available to some students with health care disparities. based system of care, which is especially important for those
Children from low-income and racial or ethnic minority families living in rural communities. Using tSBHC, children can
populations in the U.S. are less likely to have a conventional receive coordinated care right from their school, which increases
source of medical care and are more likely to develop chronic access to care for these rural students while increasing their
health problems than are more affluent and non-Hispanic white in-school time. (Children’s Health Fund, 2016; Ollove, 2017;
children. They are more often chronically stressed, tired, and Reynolds & Maughan, 2015). This equates to improved academic
hungry, and more likely to have impaired vision and hearing— performance and fewer school absences. Additionally, many
obstacles to lifetime educational achievement and predictors tSBHC enable the child’s own primary care provider or specialty
of adult morbidity and premature mortality. If school-based provider to see the patient remotely.
health centers (SBHCs) can overcome educational obstacles and The school nurse provides the initial healthcare contact with
increase receipt of needed medical services in disadvantaged a child sick at school. Likewise, the role of the telehealth
populations, they can advance health equity (Knopf et al., 2016). school nurse includes initial assessment of the sick child and
initiation of the telehealth visit. The telehealth school nurse
Evidence-based practice! Substantial evidence exists serves as the telepresenter, which enables the remote provider
supporting SBHC systems role in improving outcomes to evaluate, diagnose, and treat the child via the virtual visit.
(educational and health) in students with health, social, A variety of telehealth technologies can be used to develop
and economic disparities. SBHC systems can provide tSBHC programs. Live videoconferencing offers availability of a
healthcare services such as those relating to primary care, multitude of primary or specialty provider consultations and can
mental and behavioral health, chronic disease management, be accomplished using computers or TV screens, or by using a
social services, health education, oral health, vision health, telehealth cart for the encounter. Telehealth peripherals are an
and nutrition. School-based nurses serve to support vital important component as they allow the school nurse to assist
communication between providers, educators, families, in the diagnosis and evaluation of the sick student for real-time
caregivers, students, and the community (Knopf et al., 2016). communication, assessment, evaluation, and treatment. The
telehealth school nurse, therefore, uses technology as a tool to
enhance the care and care coordination of the school-aged child.
This equates to not only the usual primary care management, at-risk students, care coordination with providers and families,
but also to the provision of chronic and specialty care. Additional and case management.
roles of the telehealth school nurse include improving care for
Ellie’s daughter, Rowe, has been having some behavioral issues
at school. Ellie tried to find a local mental health provider but Self-Assessment Quiz Question #4
found that an appointment could not be scheduled for six Apply your knowledge of the telepresenter role to best answer
months due to the practice’s high volume of patients and low the question of what role the nurse has in the virtual care visit:
number of providers. The school nurse contacted Ellie to inform a. The telepresenter is a health care provider at the remote
her they have tSBHC in place at Rowe’s school and that Rowe site who presents the patient to the provider and assists
could see the mental health provider while at school that very in clinical assessment and physiologic or imaging data
week. As they talked about the program, the school nurse spoke collection.
about the telepresenter role that she has in tSBHC. b. The telepresenter is a health care provider at the remote
site who presents the patient to the provider and but does
not assist in assessment and physiologic or imaging data
collection.
c. The telepresenter prepares the patient, the technology,
and the environment for the virtual care visit and assists the
provider in the evaluation of the patient.
d. The telepresenter prepares the patient and the
environment for the virtual care visit, assisting the provider
in the evaluation of the patient while only the IT staff
ensures technology is working for the encounter.
APPLICATION OF TELEHEALTH IN DISASTERS AND EMERGENCIES, EPIDEMICS AND PANDEMICS
Use of telecommunications in natural and human disasters and emergencies
Natural disasters and emergencies disrupt individuals, of wireless technologies in a disaster followed the 1985 Mexico
communities, regions, and even nations. Telehealth has been City earthquake where the National Aeronautics and Space
increasingly employed over the past four decades to assist Administration (NASA) successfully employed their Applied
in anthropogenic and natural disaster response, including Technology Satellite 3 (ATS-3) to assist disaster rescue and relief
pre-planning, acute phase, and post-disaster recovery (Ajami & Lamoochi, 2014).
response (Doarn, 2014). During an emergency or disaster, Telehealth moved into the hospital setting as its application
widespread interruption of power, basic communications, and to assist in emergency care was realized. Evidence for use of
telecommunications may occur. Infrastructure can be significantly telehealth technologies in emergency and disaster situations
destroyed, including infrastructure for the healthcare system was demonstrated in the 1980s Space Bridges Program,
serving the disaster region. Communication is crucially needed which was one of the first implementations of wide scale
to coordinate information, emergency medical assistance, and telehealth for emergency services. Space Bridges began in
vital resources during the disaster and disaster relief. 1980 as a joint venture between the United States and the
Nursing Consideration: Disasters commonly force people Union of Soviet Social Republics (USSR). The Space Bridges
to quickly evacuate their homes, often leaving without their program was converted to a telehealth program when disaster
necessary medications and medical equipment, and the struck on December 7, 1988, with the Spikak earthquake in
telehealth nurse has an important role in connecting remotely Armenia, where the earthquake destroyed the majority of
with patients during such emergencies to assess care needs. Armenia’s healthcare infrastructure and vital medical services
(Vladzymyrskyy et al., 2016). This telehealth system provided
Disasters commonly cause a multitude of injuries, both non-life-
telehealth support for the people affected by the disaster for
threatening (such as minor wounds or burns) and life-threatening
about two months, enabling needed care via teleconsultations
(such as multiple traumas, radiation injury, smoke or chemical
for 209 patients. The project was a success and was the first
inhalation, or severe burns). The application of telehealth in
to demonstrate that telemedicine could be deployed across
these disaster and emergency situations provides a lifeline
geographic regions, across cultures, and across countries to
for medical and resource communications and provides those
benefit healthcare delivery for disaster relief (Vladzymyrskyy
injured access to medical care. Telehealth can, therefore, be
et al., 2016). Space Bridges was employed again June 4,
used as an effective tool for disaster and emergency response
1989, when two passenger trains collided in Ulfa, Russia,
(Doarn, 2014). Telehealth can support disaster response and
causing an oil pipeline explosion. This response used real-time
recovery through providing connections with needed specialists
telecommunications to provide emergency assistance and care
not otherwise available. With the increasing advancement
during the disaster. Over 400 nurses and physicians from both
and capabilities of telehealth technologies, telehealth is used
the United States and Ufa were involved in the care delivery. This
increasingly to provide needed support, communication, and
event was the first to demonstrate that telehealth could be used
care delivery in disaster and emergency situations.
for emergency disaster relief in real time, during the disaster,
Healthcare emergencies have long relied on telecommunications using an existing telehealth communication networks. Nurses
for assistance establishing communications, coordinating played an important role in providing and assisting in the care
rescue and relief efforts, providing access of care for patient of these patients through telepresenting, patient education, and
management and stabilization via telemedicine consults, providing telehealth nursing care.
coordinating emergency services, as well as evacuating
Another important need in disasters and emergencies is
injured patients (Vladzymyrskyy et al., 2016). On February 9,
providing crisis management and mental health care. Mental
1878, the Journal Lancet first published an article on how the
health needs increase dramatically during disasters and
telephone was being used in emergency care (Aronson, 1977).
emergencies and telehealth has been successfully used to
Additionally, the telephone assisted with medical care during
provide mental health care. For example, during Hurricane
the 1887 scarlet fever outbreak, showing its usefulness during
Katrina, an estimated 80% of New Orleans was evacuated,
infectious disease outbreaks (Aronson, 1977). The usefulness of
creating severe emotional and psychological stress for
telehealth was clearly demonstrated in disaster and emergency
these individuals (Meehan, Health Recovery Solutions, n.d.).
responses beginning from the 1980s. For example, the first use
Telemental health services supported this essential need for
care. An example of telemental health use in disasters is the 2013). These included issues related to the following: funding,
post-disaster Gulf Coast Recovery after the 2005 hurricane regulatory, workflow, attitudes, personnel, technology, and
season in the United States. The hurricanes in 2005 left the gulf evaluation of outcomes. Workflow may greatly affect the work of
coast infrastructure, medical communications and resources the nurse in such a program. The clarity of policy and procedures
devastated. The Regional Coordinating Center (RCC) for is paramount to care delivery as formatted templates and
Hurricane Response housed in the School of Medicine at instruction manuals are necessary for practice, especially in times
Morehouse, Atlanta, Georgia, was developed to address the gap of disaster where there is high stress. Another element clearly
in mental health services by providing mental health care in the identified is that stakeholder buy-in is essential to any telehealth
recovery response by way of telehealth (Kim et al., 2013). program success and buy-in of stakeholders includes the nurse
and the patient.
Nursing Consideration: Telemental health has shown
evidence of success in improving access to mental healthcare, Nursing Consideration: Telehealth champions are vital
improved outcomes, and is satisfying to patients and providers to the success of telehealth program implementation and
(Kim et al., 2013). sustainability, and this is also highlighted in telehealth disaster
response. The opportunity for the registered nurse to become
Post-program analysis was performed to assess collaborative the telehealth champion is ever present in disaster and
partnerships that improved sustainability of telehealth disaster emergency telehealth programs.
relief programs, and to discern better understanding of how
telehealth can be effective in disaster relief (Kim et al., 2013). Being a telehealth champion is an important arena for the nurse
The project found seven elements that were essential to the to consider as the telehealth champion has the attitude, skills,
success of the disaster relief telehealth program (Kim et al., knowledge, and wherewithal to lead a telehealth project to
success, motivating stakeholder buy-in and active participation.
Use of telehealth in infectious epidemics and pandemics
Telehealth has application in all healthcare arenas including use testing, or emergency transfer to the hospital. This can
in infectious disease outbreaks. Nurses have an important role be through remote home monitoring and questionnaires
in these systems of care by telepresenting, providing nursing transmitted to the provider. Teleconsultation can then be
care, remote monitoring of patients, and through delivering enacted if a patient develops symptoms that need further
patient education. Telehealth was instrumental in providing care assessment.
and assistance in recent infectious disease outbreaks, including ● For symptomatic patients who are at home, remote
the Ebola, SARS, and the MERS epidemics (Ohannessian, monitoring can be utilized to provide frequent monitoring
2015). Additionally, in March 2020, telehealth underwent rapid of the severity or exacerbation of symptoms, and live
deployment in response to the COVID-19 Pandemic. Telehealth videoconferencing can be utilized for more detailed
assessments or real-time treatments and adjustments in
is an effective tool for use during epidemics and pandemics as
management plans.
it can be used to monitor asymptomatic individuals, monitor ● For hospitalized symptomatic patients on isolation, telehealth
quarantined symptomatic individuals in their homes, enable can be used to provide care and support traditional care of
care of hospitalized symptomatic patients on isolation, and patients while mitigating exposure for healthcare providers.
care for critically ill patients through isolation communication For example, telehealth can be used to allow mental health
systems and use of eICUs. During epidemics and pandemics, providers to see, evaluate, and treat the patient without
telehealth can enable practitioners to mitigate exposure exposure risk.
through use of isolation telecommunication systems, and it ● Telehealth can also be used to maximize provider capacity,
allows practitioners to provide additional specialty consults and for example, by way of eICUs, as epidemics and pandemics
medical/nursing care. The following are examples of the use of can overrun the local provider capacity and expertise.
telecommunication systems in times of crisis: ● Patients in isolation do not see the face of the provider as
● For asymptomatic patients, telehealth offers a way for masks, gowns, and eye protections cover most of the face.
patients to communicate to providers to receive care and This can cause feelings of loneliness and isolation. Telehealth
gain information regarding any symptoms that may arise, can be used to enable the family to virtually visit the patient
and enable coordination of appropriate follow-up, diagnostic to decrease the seclusion one may experience in isolation.
Ebola
Ebola is a viral hemorrhagic disease, caused by the Ebola virus. 2. Low probability of exposure (follow-up and contact tracing).
It was identified in 1976 after two outbreaks in sub-Saharan 3. High probably of exposure but asymptomatic and with online
Africa. Between 2013–2016, it became epidemic, resulting in access (triaged to daily virtual video follow-up with a nurse
over 11,000 deaths (WHO, n.d.). It reemerged in the Democratic and contact tracing).
Republic of the Congo in 2017 and was declared a world health 4. Probability of exposure but without electronic communication
emergency in 2019. Ebola is transmitted by close contact with device (patient provided internet enabled tablet for the daily
the infected person, putting household family members at risk. nursing video assessment and contact tracing).
Also at risk are the healthcare workers caring for sick patients. Another way telehealth was used to provide care for patients
Many nurses and other healthcare workers died from exposure to with Ebola included telehealth isolation programs developed
bodily fluids containing the virus while caring for Ebola stricken to address the care needs of the patient while mitigating
patients. To combat this disease, telehealth was used to identify exposure risk for the provider. These programs enabled the
asymptomatic patients at risk, monitoring those who were nurse providing in-person care to have videoconference support
symptomatic, and providing care to ill patients. (i.e., doffing, donning of personal protective equipment, care
Telehealth was implemented in many Ebola affected regions assistance, etc.) in the room, while enabling specialty consults
throughout Africa. For example, in West Africa, teleconsultation using telehealth technologies to lessen provider exposure
was nationally available for patients needing medical care (Reichert, 2018). Using telehealth improved care of the patient,
or information (Ohannessian, 2015). The nursing role was decreased exposure and infection of others, and enabled
instrumental in these programs as they monitored, provided patients to be managed closer to home, avoiding risk of travel
counseling and education, and provided care and management and further exposure. Therefore, telehealth was used effectively
for patients. The program worked by connecting the patient to decrease disease transmission by decreasing the rate of
through the hotline to a skilled Ebola screener. The screener would spreading the virus to others, and enabled care to be delivered
then triage the caller’s symptoms as the following (Lopez, 2014): to the symptomatic patient while decreasing exposure risk to
1. No probability of exposure (education provided). healthcare workers.
Severe acute respiratory syndrome
In 2003, severe acute respiratory syndrome (SARS) was identified teleconsultation program developed by Taiwan in 2003 for the
in Asia. SARS is a virus in the coronavirus family (SARS-CoV). SARS epidemic (Ohannessian, 2015). It demonstrates an example
It took but a few short months for SARS to become a global of the use of telehealth to address care needs for the isolated
epidemic, spreading to over 24 countries in Asia, North and patient. Teleconsultation was made available for use in the
South America, and Europe (WHO, n.d.). Over 8,000 people person’s home and in the hospital to link symptomatic patients to
were ill with SARS and, of these, almost 800 people died (WHO, the provider. The nurse’s role in teleconsultation programs relates
n.d.). Symptoms of SARS include high fever, headache, diarrhea, to the telepresenter role, educating the patient on how to use the
myalgia, and cough, with most patients developing respiratory equipment and communicate with the provider.
symptoms including pneumonia. SARS spreads by aerosolization Use of teleconsultations decreases the risk of exposure for the
of respiratory droplets through close person-to-person contact. provider and enables the patient to receive medical or specialty
Fomite transmission also occurs. This makes symptomatic patient care while on isolation. A variety of technologies can be used
isolation and home quarantines necessary to reduce risk of alone or in combination for such teleconsultation programs, as
spreading the disease. both remote monitoring and live video consultations can provide
To address the need for patient isolation, telehealth was patients with lifesaving care and symptom management.
employed. One example of telehealth use includes a
Middle east respiratory syndrome
Another epidemic caused by a coronavirus was Middle East (WHO, n.d.). Most cases outside of the Middle East were in
Respiratory Syndrome (MERS). MERS first presented in 2012 people who had traveled to this region. The disease rate was
in Jordan and Saudi Arabia. As of November 2019, almost high in healthcare workers who did not have or use personal
2,500 confirmed cases have been documented, causing 858 protective equipment.
deaths (WHO, n.d.). The World Health Organization also reports One way that nurses used telehealth during MERS was to use
that people in 27 countries, including the United States, have videoconferencing and remote monitoring to provide care to
been diagnosed with MERS, having about a 35% death rate. patients in a hospital that was on quarantine (Ohannessian,
Symptoms include fever, cough, and shortness of breath. 2015). In this situation, a hospital in South Korea in 2015
Respiratory symptoms can be mild or severe with pneumonia. connected providers within the facility with patients outside
The virus is transmitted by aerosolized droplets by an infected of the facility to deliver care. The nursing role in this type of
person in close personal contact with others, such as family program includes the telepresenter role and educating the
members and healthcare workers. Eighty percent of the cases patient in the use of the technology.
were in Saudi Arabia and were thought to be due to unprotected
contact with infected people or infected dromedary camels
COVID-19
There have been four infectious respiratory pandemics affecting ill victims of this disease, while decreasing exposure to the
the United States in the past hundred years: H1N1 in 1918, healthcare worker. For example, a hospital system in North
H2N2 in 1957–58, H3N2 in 1968, and H1N1 in 2009 (CDC, Carolina reported a 500% increase in telehealth use after
n.d.). Pandemics place extraordinary stress on individuals, COVID, while Washington D.C. reported a 600% increase in
communities, states, our nation, and certainly our healthcare use of telehealth (Roth, 2020). This emerging trend will only
system and practitioners. Today, we are in an unprecedented continue to escalate, as telehealth is able to connect patients
time as we deal with the reality of the COVID-19 Pandemic. On and providers in unprecedented ways that are of extraordinary
December 12th, 2019, there were seven critically ill patients value during an infectious epidemic or pandemic. Telehealth has
in Wuhan, Hubei Province, China, reported to have a viral been implemented across facilities, communities, individuals,
pneumonia, which was subsequently found to be Severe Acute and used on a multitude of levels of engagement. Telehealth can
Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Zu et al., be used as a tool in this public health crisis because a foundation
2020). The Municipal Health Commission in China reported of telehealth technologies and models of practice already
that another 20 patients were also hospitalized with similar exists. Healthcare providers can link into existing platforms and
symptoms. The novel virus identified was thus named by the networks to access experts with knowledge and skills to assist
World Health Organization as 2019-nCoV or COVID-19 (WHO, with this rapid deployment of telehealth. With this foundation of
2019; Zhangkai et al., 2020). This infection has rapidly spread practice skills and infrastructure, telehealth is now being scaled
across Asia, Europe, the Americas, Australia, and Africa, virtually to enormous levels to provide virtual care throughout our nation,
across the entire globe. and around the world.
This emerging disease has placed extraordinary strain on In order to more easily use telehealth, some of the regulatory
healthcare systems around the world, including our own. Life barriers have been lifted during the COVID Pandemic by the
virtually changed overnight. Businesses were ordered to close, Federal Government Centers for Medicare and Medicaid (CMS),
laying off millions of employees. Workers were ordered to stay some states, and some private third-party payers. The Federal
home or work from home. Most Americans have been mandated Government 1135 waiver includes changes such as removing rural
to stay in their homes and only go out when absolutely and site limitations, so the waiver allows telehealth services to
necessary for food, medicine, exercise, or needed medical or be provided regardless of geographic location or originating site
emergency care. This novel virus has changed the very essence (CMS, n.d.). Eligible services, providers, and modalities have been
of our lives and certainly our healthcare system due to the need expanded allowing for ease of connections between the patient
to care for infected isolated patients and to provide regular and provider. Individual states have also enacted changes to
care to unaffected patients, without exposure to patients or accommodate telehealth services, including allowing providers to
healthcare workers. New strategies were suddenly needed to practice across state lines without licensure in each individual state
deal with the rapidly escalating crisis. (CCHP, n.d.). Many of these longstanding legal and regulatory
Telehealth has a significant role in response to COVID, as barriers to telehealth have been relaxed with the rapid, seemingly
evidenced by its rapid deployment through healthcare systems overnight transition to wide scale telehealth use.
throughout the United States. Of immediate importance in an Additionally, since rules now allow the originating site to be the
epidemic or pandemic is to identify exposed individuals and patient’s home, a lack of medical peripherals creates barriers to
isolate them, track and isolate contacts, isolate and monitor obtaining patient assessment. Creative providers can use devices
symptomatic patients, and care for hospitalized and critically the patient may have at home, such as a blood pressure cuff,
an O2 saturation monitor, a home glucose monitor, an Apple the virus. Additionally, telehealth can be used to provide crisis
watch, a FitBit, or apps that measure heart rate and rhythm, and counseling and mental health care. Telehealth is a powerful
oxygenation, along with a flashlight to augment assessment. tool to enable patients to receive care during times of wide-
Nurses and providers need to be resourceful at this time to spread need for isolation. Telehealth allows these patients to
obtain the assessment needed. be evaluated and appropriately treated or triaged for additional
care.
Nursing Consideration: The rapid deployment to telehealth
To summarize, telehealth technologies are an essential tool to
in the COVID-19 pandemic has created its own unique set
expedite care during outbreaks of infectious disease and can
of challenges, such as privacy concerns with non-HIPAA
be used for the following:
compliant platforms, lack of nursing knowledge on how to
● Evaluate and reassure patients about their exposure,
use telehealth in practice and how to implement telehealth symptoms, and actions to take to mitigate spread or receive
programs, lack of prior hands-on skills, lack of confidence using care.
the technology, and lack of knowledge in troubleshooting the ● Connect with patients and providers to enable assessment
technology. and decisions to be made regarding who needs to be seen
Telehealth can be used in a variety of ways to provide care in person or in hospital or for urgent care, as well as who is
during a contagious disease outbreak, where isolation of appropriate for continued home quarantine.
asymptomatic people shedding virus and isolation of patients ● Remotely monitor exposed but asymptomatic patients.
● Monitor symptomatic patients via home monitoring, which
with the disease is paramount to stopping the spread.
can prevent the spread of the disease.
Telehealth is being used to monitor those quarantined in their ● Treat symptomatic and ill patients remotely.
homes that are symptomatic, and it is being applied to the ● Provide care for those with existing mental health disease or
hospitalized patient to provide access to specialty care via those with new mental health issues due to the stress of the
telemedicine consults, intensive care via eICUs, and to provide crisis.
in-room assistance to the nurse or provider for the hospitalized ● Protect providers and mitigate risks of exposure while caring
isolation patient. Telehealth helps to mitigate healthcare worker for patients.
exposure through remote monitoring and virtual consults. ● Provide specialty consults for patients ill with the disease
Telehealth also enables timely care delivery. Provider efficiency and for those requiring specialty care for other reasons.
with telehealth enables more patients to be seen. Since there is ● Increase workforce response to the crisis.
no travel required for the patient with the relaxed rules, patients ● Maximize workforce by enabling quarantined staff to work
can be seen at home, avoiding long travel times and potential remotely.
exposure to illness when being seen in person. ● Ensure brick and mortar facilities are reserved for those
needing in-person care.
Telehealth has a wide range of uses to assist the provider in ● Provide access to infectious disease and pulmonology
times of epidemics and pandemics. For example, a patient specialists.
with medical risk factors who suspects they may have been ● Increase provider availability in geographically underserved
exposed to the disease can contact a provider using telehealth regions.
technology. The provider can take a detailed history and ● Enable provision of routine care, especially to those with
assess the patient for symptoms. If symptomatic, the provider chronic conditions, thereby decreasing patient exposure risk
can give management recommendations, which may include and keeping them at their maximal health status.
quarantining at home or transfer to the hospital. If transferring
Since contagious disease outbreaks require symptomatic
to the hospital, the provider can connect with the local EMS to
patients to be isolated, telehealth provides a way for patients
advise and facilitate safe transfer. The provider can document
to receive care while helping to mitigate the patient and the
the interaction in the electronic medical record so it is available
provider’s risk of exposure. However, many patients have never
for the ED provider when the patient reaches the hospital.
had a telehealth encounter and they will need instruction,
Otherwise the telehealth provider can facilitate an appropriate
information, advice, and education on how to use this as a
level of treatment, ensuring the safest care possible by not
tool for receiving their care. This will enable patients to gain
exposing the provider or any other healthcare professional
comfort, confidence, and satisfaction with this method of care
unnecessarily. Telehealth can also be used during this time to
delivery. The nursing role as telepresenter and tele-educator is
meet care needs for patient with asthma, diabetes, heart failure,
therefore an important role of registered nurses as they assist
or other medical disorders who may be hesitant to be seen for
with care delivery and educate patients on how to engage with
an in-person visit in a care facility for fear of being exposed to
the technology and providers using telehealth.
Case study - Phase 3
Mel recently developed a fever and was sent home from school Clinic so that she can assess him more frequently and assess
as schools began closing to decrease exposure to the COVID-19 for any decline. This clinic gives patients an iPad, enabling live
virus. Since he lives in a remote area, the school nurse set him up videoconferencing and medical peripherals to obtain and upload
as a patient in the school’s Interactive Remote Monitoring COVID vital signs at prescribed intervals.
LEGAL AND REGULATORY CONSIDERATIONS OF TELEHEALTH NURSING PRACTICE
Privacy and security
Telehealth is distinctively involved with the use of advanced virtual care environment (Zhou et al., 2019). Both patients and
telecommunication technologies in healthcare entailing providers must gain trust using telehealth. Nurses can reflect
bidirectional transfer of sensitive healthcare data and upon how privacy and security of patient data is adhered to
communications. There are, therefore, privacy and security in traditional practice and consider how this translates to care
considerations when collecting, accessing, and transmitting in the virtual care environment. Federal and state healthcare
patient private health information. Just as there are laws data regulations are applied to telehealth practice, although
and regulations for use of patient private information in rules and regulations that more specifically address telehealth
the traditional care environment, there are also laws and practice are needed. Basic guidance can be found in the HIPAA
regulations guiding practice in the virtual care environment. rules as telehealth programs and services must abide by this
There have been numerous healthcare data breeches in federal framework for practice. There are also individual state
recent years and public trust in telehealth must be gained by rules and regulations that the nurse must be aware of, and it is
active adherence to rules, regulations, and development of necessary to review the telehealth practice laws of the state in
protocols to protect patient data and communications in the which the nurse is licensed. Privacy risks relate to how patient
data is collected, used, transferred, and, of course, disclosed provider can use the camera to scan their room to show the
to others. For example, in telehealth, privacy could be violated patient there is no one else in the room where the encounter is
if a home remote monitoring device inadvertently transmitted taking place.
to outsiders when the home was vacant or transmitted other
unintended data. Since HIPAA rules were designed to address Self-Assessment Quiz Question #5
patient data security and privacy in the clinical care setting, they
Remote monitoring is an effective way of increasing the
should be reviewed for better application to the virtual care frequency of monitoring and management of Mel’s condition.
setting where the patient is receiving care in locations other Select the best response that relates to the benefits of remote
than a traditional care setting (Hall & McGraw, 2014). Telehealth monitoring.
systems also need to be compliant with active security a. Remote patient monitoring is not appropriate for
measures and controls, including data storage and transmitting biometric data evaluation since patient feedback is
encryption, virus and malware protection, control of patient necessary due to the use of telecommunications.
data behind secure firewalls, audits to assess effectiveness, b. Remote patient monitoring enables patients to be
and a framework of protocols to provide adequate assessment assessed more frequently than is possible with in-person
and response to issues that may arise. Transfer of sensitive visits, although patient education cannot be performed in
patient data over the internet presents a unique set of privacy conjunction with data collection.
c. Remote patient monitoring enables patients to be
and security concerns. This necessitates virtual systems of assessed more frequently than is possible with in-
healthcare to be aware of these risks and build systems that person visits, enabling data trends to be monitored and
enable protection of patient data through all forms of usage. management plans adjusted.
Additionally, the HITECH Act provides regulatory guidance d. Remote patient monitoring is appropriate for
connecting the patient as a site of care delivery in telehealth psychological data and imaging as it enables more
practice (USDHHS, 2009). Lastly, mobile medical devices frequent assessment but should not be used for symptom
used in healthcare are regulated by the U.S. Food and Drug management.
Administration (FDA), including medical apps (Hall & McGraw,
2014). Nurses must be aware of the issues related to patient Nursing Consideration: Nursing knowledge related to
privacy in the virtual environment to provide secure use of privacy and security of communications and data in the virtual
PHI, as there are unique privacy and security concerns when environment is an important aspect of proficiency in nursing
using telehealth. For example, to ensure a patient’s privacy, the telehealth practice.
Nursing scope of practice
Telehealth enables professional nurses to provide nursing care Standards and guidelines for telehealth nursing are needed
to patients in the virtual care environment. Telehealth nurses to align with the contextual framework and regulations
practice according to the nursing scope of practice, essentially guiding nursing practice. For example, a variety of nursing
just as they practice in standard delivery of nursing care. clinical practice guidelines were developed by the American
Nurses, therefore, should explore how this translates to using Telemedicine Association to give guidance for use of telehealth
telehealth technology in nursing care delivery. The nursing in a variety of practice arenas (ATA, 2019). However, nurses
scope of practice is actualized through the state laws and must examine how telehealth impacts nursing care, such as
regulations that frame the principles and capacity of nursing with providing care across state lines, thus practicing in a wider
practice, including nursing regulations, authority for activities geographic area. Nursing licensure compacts are beginning to
in nursing practice, and standards for nursing practice. The address these issues by enabling multistate licensures across
State Board of Nursing and Medicine Nurse Practice Acts state lines (NCSBN, 2018). This serves to facilitate telehealth
regulate registered nursing scope of practice in each state. In nursing practice by eliminating barriers to telehealth practice,
addition to defining the activities, roles, and responsibility of providing interstate telehealth nursing practice opportunities.
the registered nurse, they delineate the education required for Eliminating geographic practice barriers would leverage nursing
the registered nurse. There is variability state to state among to expand the reach and breadth of telehealth nursing services.
nurse practice acts so nurses are encouraged to be familiar Additionally, telehealth nursing will need to examine how the
with the nurse practice act in their state of licensure. Telehealth art and science of nursing can be operationalized based on
does not change the nurse practice acts, nor is it in conflict with the nursing scope of practice in the virtual care environment
them. Nurses have long used diagnostic tools to deliver care, (Fronczek, 2019).
and telehealth is just another tool or medium with which to
augment nursing care delivery.
Licensure
Multistate licensure and license portability are essential use of Nursing Compacts for license portability is available.
aspects of telehealth nursing laws and regulations. States have Registered nurses have the enhanced Nurse Licensure Compact
the legal authority to grant, maintain, and regulate nursing (eNLC), which grants license portability (NCSBN, 2018). The
licensure. However, healthcare delivery across state lines is eNLC enables registered nurses and licensed practical and
governed within the Intrastate Commerce Act, which essentially vocational nurses in the member states to gain licensure in
prohibits practitioners from practicing across state lines without other member states, thereby enabling nurses to care for
being licensed in each state of practice (Gupta & Sao, 2012). patients in the member states. Under the agreement, uniform
Professional licensure for telehealth requires that practitioners licensing requirements have been defined and must be met
be licensed in the state where the patient is located and to practice under the eNLC (NCSBN, 2018). Thirty-four states
receiving the care (originating site) (Blackman, 2016). Telehealth have enacted legislation permitting nurses to join the eNLC as
transcends geographic boundaries, and restrictive laws of January 2020, and multiple states have pending legislation
prohibiting practitioners from practicing across state lines (NCSBN, 2018). The eNLC allows registered nurses to use
without a license in each state are a barrier to telehealth telehealth in the member states, eliminating this barrier to
practice and dissemination. License portability, which allows the nursing telehealth care.
practitioner to gain licensure in additional states, is a strategy
to overcome this barrier to care delivery. The registered nursing
profession has an advantage, as telehealth practice with the
Alignment with bachelor of science in nursing (BSN) essentials
The BSN Essentials document emphasizes such concepts as Privacy and security of patient data and communications is
patient-centered care, interprofessional teams, evidence-based paramount to protecting patient’s rights and safety. Just as in
practice, quality improvement, patient safety, informatics, traditional in-person care, privacy of data relates to how data
clinical reasoning/critical thinking, genetics and genomics, and communications are collected, shared, and transferred.
cultural sensitivity, professionalism, and practice across Security of data and communications also relies on secure
the lifespan in an ever-changing ad complex healthcare telemedicine systems that are compliant with state and federal
environment (AACN, 2008, p. 3). laws and regulations, including data storage and transmitting,
The BSN Essentials provides the framework for the education encryption, virus and malware protections, firewalls, audits, and
of nurses at the baccalaureate level to enable registered protocols to ensure privacy. However, during this national and
nurses to fully deliver nursing care commensurate with their global crisis, under revised guidance from the Department of
knowledge, skills, and experiences (AACN, 2008). Telehealth is Health and Human Services Office of Civil Rights, allowances
supported by the BSN essentials since telehealth is a tool for are being made for use of non-HIPAA compliant platforms.
nursing care delivery. The Essentials of BSN practice is therefore During this time of national emergency, Apple FaceTime,
consistent with expression of nursing telehealth practice. Facebook Messenger Video Chat, Google Hangouts Video,
Using telehealth as a tool, the BSN can accomplish all 9 BSN and Skype are acceptable for use for telehealth encounters.
essentials. Additionally, Essential IV: Information Management However, platforms that allow the public to access the
and Application of Patient Care Technology specifically states encounter are not authorized for telehealth use, including
that the BSN prepared student will have knowledge and skills in Twitch, TikTok, and Facebook Live.
patient care technology (AACN, 2008).
Case study - Phase 4
Mel is on day 7 of 14 of his COVID-19 quarantine and is still house for the rest of the quarantine; however, he wants to
feeling ill with fever and myalgia. He intends on completing use FaceTime Live to connect with the nurse practitioner who
his quarantine using the secure platform in the COVID-19 is working in the Interactive Monitoring Program instead of
Interactive Remote Monitoring Program. His friend, Nick, who is using the telehealth equipment that was given to him for the
also in the COVID-19 Interactive Remote Monitoring Program, monitoring program.
is feeling a little better and plans on going to his parents’
TRANSLATING TRADITIONAL NURSING CARE TO THE VIRTUAL ENVIRONMENT
Knowing nursing
Practicing nursing in the virtual environment can be about how telehealth changes practice, so that questions about
conceptualized using existing frameworks, models of nursing this new way of practicing can be considered. Nursing has its
knowledge, patterns of knowing, and knowing the patient unique perspective as a practice discipline through identification
as outlined by Carper (1978). We can translate nursing care and application of the ways of knowing in nursing. The ways of
from traditional nursing practice to the virtual environment by knowing are intertwined in practice and are essential for holistic
utilizing knowledge and skills in current nursing paradigms. practice and understanding nursing knowledge. Four types of
Carper provided insight into our patterns of knowing in nursing knowledge were identified as most valuable as a foundation for
and wrote that understanding these patterns was essential to nursing. These include empirical, which is the science of nursing;
learning nursing and to being able to teach nursing (Carper, esthetic, which is the art of nursing; personal knowledge, where
1978). Each professional practice discipline establishes its body one uses the therapeutic self; and ethical, which provides the
of knowledge through unique frameworks and determines how moral reasoning for nursing.
that information is structured, established, and applied. The
patterns of knowing in nursing are used to inspect and assess Self-Assessment Quiz Question #6
knowing in nursing, and this examination allows nursing to
Select the best response from the nurse to Nick:
develop a particular perspective according to the significance a. Since Nick is feeling better and wants to be with his
placed on such knowledge (Khuan, 2006). family, it is his choice to use FaceTime Live since this
The nursing body of knowledge is foundational to nursing platform has been given allowance for use in telehealth
practice and provides nurses with ways to think about and encounters during the COVID-19 Pandemic, as long as he
consider elements essential to nursing knowledge and practice. checks in with the nurse every four hours.
This understanding requires nursing to understand what it b. It is best if Nick uses the telehealth equipment given
to him for use in the program as it is HIPAA compliant
means to know and determine what kinds of knowledge are and has privacy and security measures implemented
essential to the discipline and practice of nursing in the virtual in the program; however, since he will be traveling it is
environment. Knowing has enabled discovery in nursing, acceptable for him to use FaceTime Live to check in as
enabling questions to be asked that stimulate thought on long as he remains afebrile.
nursing care. This rings true with telehealth, as nursing must c. Nick can transfer his telehealth programs to his FaceTime
incorporate telehealth into our conceptual framework of nursing Live platform since it is HIPAA compliant, so that he can
to allow for the changes that will occur. connect to the nurse in the monitoring program.
d. Nick can use other platforms, such as Apple FaceTime,
Nursing Consideration: Telehealth allows for new Facebook Messenger Video Chat, Google Hangouts
perspectives in how to apply nursing knowledge. This will Video, and Skype to engage in other telehealth
require nursing to consider questions that will bring about encounters during the COVID-19 crisis as allowances
new insights as to how to use telehealth technology in the have been made. However, he should continue to use
virtual environment and how to care for the patient in the the program’s HIPAA secure equipment to complete this
virtual environment. telehealth monitoring program.
When the correct questions related to telehealth nursing Scientific inquiry into telehealth nursing practice provides
have been asked and, in turn, answered by nursing, solutions the empiric basis for practice, bringing new perspectives to
regarding use, effects, additions, and modifications to nursing consider as we move forward into this new age of care. Nursing
care will be determined. Telehealth must be conceptualized is encouraged to provide this evidence for telehealth practice
in the nursing paradigm so that it can be used to critically think through new discovery. A highlighted question when using
telehealth is whether the esthetics and art of nursing can be
translated to virtual practice. The ability to form presence with will be presented as a result of telehealth technologies. The
the patient in the virtual environment is a major consideration ways of knowing affect nursing by supplying a scientific base
in this translation. Once the nurse and patient connect with of knowledge of human behavior throughout the spectrum
presence in the virtual environment, the nurse can then transmit of health, while esthetic considerations of humanness and
the art of nursing to the care in the virtual environment utilizing personal knowledge of the self are layered onto ethical and
existing and new skills to affect the art of nursing in the virtual moral insights for decision making (Carper, 1978). Telehealth
arena. It is important that personal knowledge be used in virtual allows for new perspectives in how to know nursing and
nursing as it is in traditional care, so that nurses can fulfill this enables a focused awareness of the range and complexity of
essential element of the nursing discipline regardless of the nursing knowledge in this technological age.
environment of care. Nursing should further explore how the
therapeutic self is perceived and utilized by the nurse and the Nursing Consideration: Exploring these patterns of knowing
patient in virtual nursing to determine effectiveness of nursing in the virtual environment and their effect on nursing serves to
telehealth. As more nurses engage in virtual practice, new facilitate development of the nursing discipline. These patterns
ethical situations, questions, and dilemmas will arise. Nursing of knowing can be applied to telehealth nursing practice
will use critical thinking in the context of the codes of ethical and can contribute to the development of the integration of
practice to determine best solutions to the new questions that telehealth technology into the practice of nursing.
Knowing the patient

The process of knowing the patient is an assimilation of the environment and is an essential element of nursing in virtual
ways of knowing in nursing, and these patterns of knowing practice, just as it is in traditional practice.
can be used to know the patient in the virtual environment. Ethical knowing of the patient involves moral judgments and
Empirical knowing relies on evidence-based practice requires interaction with the patient to explore and clarify
considerations and is in the realm of scientific knowledge. the meaning and value of the nurse-patient relationship. It
Esthetic knowing of the patient relates to forming an accurate is based on what is right and just according to the role and
perception of the patient through a trusting relationship. responsibilities of the nurse. Ethical knowing of the patient in
Personal knowing is immersed with use of the therapeutic self. the virtual environment can be gained by having presence with
Ethical knowing of the patient is based on perceived rightness the patient and utilizing traditional nursing ethical principles to
in care for the individual. The nurse can engage with the guide clinical judgments.
patient in the virtual environment and actualize the process of
knowing the patient using these patterns of knowing in nursing. Evidence-based practice! Knowing the patient is inherent
Knowing the patient requires knowing the patient as a person to nursing practice and is an essential element in decision
and knowing their pattern of responses (Carper, 1978; Tanner making, clinical judgment, clinical knowledge, and the ability
et al., 1993). Nurses must gain confidence and skills in forming to advocate for the patient (Mantzorou & Mastrogiannis, 2011).
these relationships and extracting this information virtually. Knowing the patient is based on science in nursing as empirics
The nurse must be able to form a personal relationship and serves to provide facts based on discovered evidence, which
get to know the patient as a person in the virtual environment are used to explain and predict the caring relationships
so that practice considerations and decision making in nursing (Mantzorou & Mastrogiannis, 2011). As evidence for telehealth
will reflect the personal attributes, values, and wishes of the nursing practice is further discovered, the scientific foundation
patient. Knowing the patient in the virtual environment is key for virtual practice will be strengthened and nurses should play
to best judgments about care for the patient. Knowing the a leading role in nursing research to identify this evidence.
patient can be related to the time spent with the patient, so
length of time and quality of time spent with the patient in Personal knowing is associated with knowing the self, since
the virtual environment must be further explored to determine through knowing the self, one can then know another (Chinn
technology’s effect. & Kramer, 1991). This leads to embracing the therapeutic
Esthetic knowing is a core element of nursing as a practice- self, where the nurse uses self as a tool in the caring process,
oriented discipline. It is suggested that it is the understanding leading to a meaningful nurse-patient exchange. Personal
of esthetic knowing that contributes to how nurses know knowing of the patient in the virtual environment utilizes
patients (Benner, 1982). Traditional nursing skills related to knowing of the self and offering the therapeutic self to improve
esthetic knowing are able to be used in the virtual practice care, just as it does through in-person care, although use of
environment; however, nurses will need to consider, reflect, therapeutic touch is absent. Strategies to enhance receiving
learn, and practice translating these skills to telehealth nursing and conveying the therapeutic self should be explored to
practice. Esthetic knowing of the patient requires the nurse ensure confidence of the smooth transition of traditional
to be fully present with the patient. Presence requires the nursing to nursing in the virtual environment. Personal
connection to the patient, engaged in the moment, so as to knowledge in relation to successful clinical decision making
synthesize and extract the meaning of the interaction and act is aligned to high-quality patient relationships (Jenks, 1993).
upon the derived meaning (Smith, 1992). Presence is able to Clinical judgment requires knowing the patient through the
be formed between the patient and the nurse in the virtual personal relationships that nurses form with patients in all
environments of care.
As Ellie engages with patients using telehealth as a registered relationship in the virtual environment. Ellie wonders how
nurse in the ambulatory clinic, she considers how she can retain she can connect with presence with the patient during the
the essence of nursing by knowing nursing, the patient, and the virtual encounter as she does during the in-person encounter.
technology in the virtual environment. Translating the art and Additionally, Ellie is skilled at using the therapeutic self when
science of nursing to the virtual care environment is essential to caring for patients in the traditional environment but is not sure
caring for patients and forming the therapeutic nurse-patient how these skills will transfer to the virtual care environment.
Knowing the technology
Nurses have long used technology to aid in care delivery by bodies, including their senses, and the use of inanimate
improving assessment, diagnosis, and treatment of patients objects, devices, and tools to facilitate care (Sandelowski,
and facilitating communication with patients, specialists, and 2000). These first devices were simple items found in the
colleagues. Sandelowski (2000) points out that the first nurses home such as needles and thread, watches, and matches
(1870s–1930s) had two resources to provide care: their physical (Sandelowski, 2000). Over time, more specialized devices and
technologies allowed nurses to extend their ability to provide help nursing know the patient, such as in using technology to
nursing care to patients using thermometers, hypodermic collect data remotely, and engage with the patient to provide
needles, and stethoscopes. We now have advanced telehealth care virtually. Nurses are becoming involved in telehealth nursing
technologies, which allow nurses to be virtually transported care at an ever-increasing rate, and empirical evidence to supply
to patients in remote sites to provide nursing care. Knowing the knowledge base for virtual nursing practice is needed to
nursing allows for knowing the patient by way of providing care, guide practice. There are many challenges to filling this gap in
forming the nurse-patient relationship, and engaging in expert knowledge, including lack of unified precedent to incorporate
practice through knowing as an essential component of nursing telehealth nursing education into nursing practice. Additionally,
practice (Zolnierek, 2013). more evidence to support nursing telehealth practice by way
of outcomes data and effectiveness is needed. The esthetics of
Nursing Consideration: We live and practice increasingly in knowing the technology relates to the connection of presence
environments of care that are representative of reality; and a that forms between the nurse and patient in the virtual
major issue remaining for us is to understand the relationships environment by use of the technology and nursing skills to form
between persons and the influence of changing contexts of presence. Presence enables nurses to explore significance in
care” (Locsin & Purnell, 2009, p. 373). caring patient-nurse exchanges as essential elements of being
there for the patient. Presence is an important concept in virtual
These changing contexts of care include practicing nursing in nursing practice and is a needed skill in knowing the technology.
the virtual environment. Knowing the technology is an essential Use of senses is an important construct in nursing as well. Nurses
element in the nursing telehealth paradigm. Therefore, foster and develop skilled senses of sight, hearing, touch, and
technological competence is a requirement of telehealth smell to provide the intensity of observation that allow the
nursing practice. Additionally, technology can be a platform nursing profession to develop into its own science.
for helping the nurse to know the patient through interactions Personal knowing of the technology relates to comfort and
within the virtual environment. One of the most common confidence among nurses in telehealth use. Use of self in
themes in nursing research on knowing the patient was time: guiding the patient to engage in the virtual environment enables
time to talk with and conduct assessments as well as provide the technology to fade into the background, as the bond of
education and nursing care (MacDonald, 2008). Technology can presence grows stronger. Nursing experience is a factor that can
increase the frequency and length of time the patient interacts improve understanding of patient responses to care; additionally,
with the nurse, helping to improve knowing the patient. experience and proficiency with the technology is paramount
(MacDonald, 2008). Ethical knowing of the technology involves
Self-Assessment Quiz Question #7 valuing and clarifying the meanings in the care and decision
making in accordance with nursing ethical practice in the virtual
What should Ellie consider as a nurse to prepare her to bring world. New discussions to resolve moral dilemmas will occur in
the essence of nursing to the virtual care environment? nursing using creative critical thinking as we strive to analyze and
a. Nurses can translate nursing skills and knowledge from account for changes from traditional practice. Further research
the traditional nursing environment to the virtual care and nursing scholarship are important to explore as nursing
environment by using existing frameworks for practice, is transformed in the midst of this technological age and has
models of nursing knowledge, and patterns of knowing, potential to shape the body of knowledge related to patterns of
along with current knowledge and skills.
technological knowing in nursing.
b. When nurses consider questions about the virtual
care arena and nursing practice, development of new
paradigms for care is not needed. Self-Assessment Quiz Question #8
c. Since telehealth uses technology to deliver care, it is Nurses use tools and technology in everyday traditional
not possible to use the ways of knowing in nursing to practice, such as when using the stethoscope or automatic
provide a framework for understanding care in the virtual blood pressure machine. Technological knowing in telehealth
environment. relates to application of technology to practice in the virtual
d. Telehealth is equal to traditional care; therefore, it does environment and includes competence with the technology
not present new questions related to translating nursing and an understanding of how presence can be formed with
practice to the virtual care environment, including issues
the patient.
related to nursing ethics and moral reasoning.
What other aspects of technological knowing are important
Nursing Consideration: “It is important to remember that to telehealth nursing?
a. Personal knowing of the technology relates to the
technology is but one way of knowing in nursing, and the confidence and comfort the patient displays when using
others must also be nurtured in tandem to have patient care the technologies in practice.
work environments that provide balance and flow to the b. Use of senses (such as sight) is not altered in telehealth,
work” (MacDonald, 2008, p. 154). as reliance on vision is equal in traditional care and
telehealth care.
Telehealth allows knowing to occur in nursing through c. Moral dilemmas in virtual care delivery will not arise since
technological knowing as well. Technological knowing relies on the patient and provider are in separate locations.
the study of empirical evidence and knowledge that supports d. Skills are valuing and clarifying ethical practice in the
the development of the technology, its use and application to traditional nursing arena can be used as a foundation to
practice in the virtual environment. Knowing the technology can consider issues that arise in virtual practice.
TELEHEALTH COMPETENCIES FOR THE REGISTERED NURSE IN THE VIRTUAL CARE ENVIRONMENT
Enhancing communication skills
Nurses must communicate effectively to provide accurate ● Asking questions in a nonjudgmental way.
patient assessment, education, and nursing care. Effective ● Providing feedback.
communication is also especially important when using ● Being “with” or being present.
telehealth technology, as it helps to build trust, improves ● Portraying a friendly and nonthreatening attitude.
understanding, and lends clarity to discussion. It fosters ● Being confident.
engagement between the patient and the provider. Traditional ● Showing empathy and respect.
nursing communication skills can be used in the virtual care ● Understanding nonverbal cues from the patient.
environment, including the following: Methods like teach-back can be incorporated into the
● Active listening. telehealth visit and, with patient permission, families can also
● Summarizing and reflecting upon what was heard. be present for better conveyance of healthcare information.
● Use of nonverbal communications. Language barriers can be addressed by use of virtual translators
to ensure effective communication. However, one main use of nonverbal behaviors and improved active listening can
difference when using telehealth is that the nurse and the help both patient and nurse engage and feel presence.
patient are not in the same room.
Nursing Consideration: Looking right into the camera so the
The use of cameras and technology adds a layer of change
patient perceives the nurse “looking into the patient’s eyes”
when interacting, and this needs to be considered. Sometimes
can improve the communication and feelings of bonding,
one’s own image on the screen can be distracting if not
just as looking into one’s eyes during face-to-face encounters
practiced with regular use. Proficient hands-on skills with the
improves engagement.
technology are a must, as the technology should work and
not delay a patient encounter. Additionally, the nurse will Additionally, careful use of voice tone and inflection can
not be able to integrate therapeutic touch with these usual better portray meanings of discussions. Practice using the
communication skills due to the remote nature of telehealth technology will enable the nurse to avoid distractions and
practice. This requires the telehealth nurse to heighten other develop confidence with the technology. This confidence can
communication skills to bridge this gap. For example, improved be perceived by the patient and improve the effectiveness of
communication during the virtual care visit.
Developing skills in telepresence
The perception of presence is a common concept, which has We can also consider how to form psychological presence
long traditions dating back to oral customs of storytelling, as with the patient in the virtual care environment. Traditional
the listener imagines being transported into the story itself. The nursing skills can be used to form presence in the virtual care
feeling of a shared experience is the basis for the concept of environment as nurses use their senses to engage mindfully with
presence. Presence is a core concept in nursing and helps to patients. Technology enables a focused window to the patient;
define nursing practice as an essential competency. therefore, skills in promoting and perceiving presence remotely
Presence can be conveyed in physical and/or psychological are essential to developing meaningful presence at a distance
interactions between the patient and the nurse. Examples of (Boeck, 2014). Boeck suggests meaningful transmission of
physical presence include therapeutic touch, just as rapport presence using telehealth can be enhanced by the following:
to build trust, to share, and to convey empathy is part of the ● Ensuring a comfortable environment of care where the
psychological therapeutic nurse-patient relationship. patient and provider feel safe and secure during the
telehealth encounter.
Evidence-based practice! Nursing presence is the “holistic ● Provider having familiarity and/or knowledge about the
and reciprocal exchange between the nurse and the patient patient; patient having familiarity and/or knowledge about
that involves a sincere connection and sharing of the human the provider.
experience through active listening, attentiveness, intimacy and ● Conveying interest in the patient’s overall well-being and
therapeutic touch, spiritual exploration, empathy, caring and reason for the visit.
compassion, and recognition of the patient’s psychological, ● Presenting oneself in an honest manner, with transparency
psychosocial, and physiologic needs” (Hessel, 2009, p. 278). that gains the patient’s trust.
Presence enables a meaningful relationship between the nurse ● Being mindful of verbal engagement, including speech
and the patient. However, caring for patients using telehealth pitch and tone, to correctly express important messages
and meanings.
leads to questions on how to convey nursing presence with
● Being aware of the increased importance of nonverbal
patients in the virtual care environment since physical presence language in videoconferencing as this plays a greater role in
is absent. the virtual care environment. For example, facial expressions
are important to the perception of listening.
Nursing Consideration: “Our presence is one of the most ● Being experienced with technology so the patient gains
powerful and important interventions nurses can offer in working comfort and confidence receiving care using technology;
with a patient and family” (Fahlberg & Roush, 2016, p. 14). furthermore, the inexperience using the technology does
not interfere with the provider’s focus on the patient or the
patient’s engagement with the provider.
TRANSMITTING EMPATHY USING TECHNOLOGY
Nursing empathy is an integral component of nursing. The do translate well. For example, the nurse can use careful tone
ability to convey empathy strengthens the connection between and inflection of voice when exploring issues in detail with the
the nurse and the patient. It is an essential element of the art patient to convey a nonjudgmental attitude, allowing for more
of nursing. Traditional methods of conveying empathy include open, honest discussions. Telehealth nurses can make better
using effective communication skills along with therapeutic use of body language when videoconferencing, such as looking
touch, as the nurse relates to the patient’s needs, feelings, and directly into the camera to facilitate patient perception of the
emotions. Conveying empathy is possible using telehealth. nurse looking directly at them and being attentive to their needs
However, the elements of how to transmit empathy in the virtual (Learn telehealth.org, 2017). Leaning in and gently nodding are
environment must be explored and similarities and differences natural ways to show empathy using nonverbal behaviors. Nurses
be acknowledged. While nurses cannot use therapeutic touch as can learn to use these techniques and apply them effectively in
an integral method in remote care, they can be aware of how to the virtual care encounter to convey empathy.
best convey empathy at a distance and amplify those skills that
Awareness of factors associated with telehealth etiquette
The telehealth encounter is improved with nursing knowledge
Nursing Consideration: Nurses should display knowledge of
and proficiency in telehealth etiquette. Telehealth etiquette
telehealth etiquette, which can be thought of as the bedside
relates to the distinctive behaviors and skills involved in
or “webside” manner for the telehealth visit. It includes
conducting virtual care encounters (Rutledge et al., 2017).
provider appearances, behaviors, and skills conveyed to the
patient during the virtual care visit.
While etiquette skills used for the telehealth encounter are Provider Performance features include the following:
similar to those used in traditional nursing care, there is ● Skill using the equipment: can use effectively and can
a specific etiquette skill set for using telehealth (Ali et al., troubleshoot.
2015). These skills can be categorized as factors affecting the ● Testing of equipment.
environment of care, provider performance, and privacy (Haney ● Available technical support.
et al., 2015). ● Camera position and appropriate zoom.
● Appropriate skill using medical peripherals.
Environment of care features include the following: ● Ability to support providers/patients at originating site to
● Auditory Considerations work through minor technical issues.
○ Telehealth uses sensitive microphones that amplify ● Avoiding multitasking and side conversations.
sound, so small noises previously unnoticed in the
traditional setting can be annoying and distracting to Privacy Considerations include the following:
the patient. Examples include tapping pencils, opening ● Ensuring privacy during visit: patient and provider should
of food containers or snacks, tapping on a keyboard, be in secure, private locations (i.e., a grocery store would
ringing of jewelry, ice in a glass, papers shuffling, not be appropriate). Visits are not usually recorded unless
chewing gum, and eating. special consent is obtained from patient.
○ Background noises may be amplified. ● Conduct a room sweep with camera so patient can see who
○ Be in a private location with door shut, mute other is in the provider’s room.
sounds or alarms. ● Obtain consent for telehealth encounter as required by
○ Others should mute microphones to decrease collateral individual states.
noises. ● Post sign on door that room is in use.
○ Volume should be adjusted for best sound. ● Ensure telehealth equipment is off or on mute, use lens
● Visual elements covers, etc.
○ Physical environment. ● Use headphones so HIPAA PHI not audible outside the
● Camera position. The nurse should use self-view to adjust telehealth encounter room.
camera and assess what the patient is seeing.
● Look at camera (instead of image of the patient) to best Self-Assessment Quiz Question #9
engage with the patient as that makes your image appear Knowing how to set up and manage the virtual care
as you are looking into their eyes.
environment is important for effective care delivery, as well
● Colors and lighting. Avoid loud colors, distracting patterns.
○ Provider appearance. as for a satisfying patient experience. Effective telehealth
● Distance from camera: Close distance of the nurse to the etiquette includes environment of care, behaviors of the
camera gives perception of closer encounter, more realistic nurse and provider, and privacy concerns.
and similar to in-person visit, increasing nurse-patient Which behaviors and skills demonstrate effective telehealth
connection. etiquette?
● Professional appearance: identification tag should be clearly a. Looking at the patient’s image on the screen as you talk
visible; hair, makeup, clothes, jewelry, and grooming should to them to engage as if you were looking into the eyes of
not be distracting. Be aware of movements as up-close the patient.
visualization can appear amplified. b. Muting microphones when not actively engaged in
conversation so that soft sounds and extraneous noises
● Provider proficiency: hands-on skills should be smooth do not distract others.
and effective so that the patient is not distracted and the c. Dressing casually in muted colored clothing instead of
encounter is not taken over by use of the technology. professional attire to better relax the patient.
d. Talking softly while in a public place and engaging in a
telehealth encounter so others are less likely to hear your
conversation.
Mastering technology technical skills
Nurses use a variety of technologies to assess and care for the nurse should have available support by the information
patients, such as the stethoscope, blood pressure cuff, automatic technology (IT) team. Additionally, patients should be given
blood pressure machine, doppler ultrasound to assess pulses, adequate instruction, education, and hands-on practice in using
and bladder scanners, to name just a few. Proficiency using any remote home monitoring equipment placed into their
technology is an essential skill of the nurse, and this applies home or with any wearable devices. In this way, the technology
to the telehealth nurse as well. Today’s technologies enable slides into the background and the encounter can continue
a multitude of platforms to assess physiologic and radiologic unimpeded; otherwise, the technology can be a glaring
data, enabling advanced communications to be integrated into obstruction to care. In addition to remote home monitoring
everyday care. Telehealth technologies can connect patients equipment and live videoconferencing, the nurse should be
and nurses in real-time virtual care environments, changing well acquainted with the use of medical peripherals to conduct
the paradigm of nursing care. Nurses must, therefore, gain the patient assessment. Individualized skill building is required
knowledge and skills using telehealth technology so that the for each specific piece of equipment as nurses are frontline
technology can aid rather than interfere with nursing care. patient educators. A variety of telehealth platforms and devices
Difficulties connecting with the patient for a telehealth visit can are available to be used in the care of the patient. However,
detract from the overall care and lead to decreased satisfaction telehealth technology can only be seamlessly integrated into
with the telehealth patient care experience. Problems such as practice if it works properly without problems or interruptions
non-connecting to a remote site, inadequate audio and visual to provide the desired care. Nurse should examine their
quality, or poor reception during live videoconferencing sessions own technology readiness and gain the skills to demonstrate
can interfere with the encounter. It is, therefore, necessary that competence using telehealth technology.
nurses gain hands-on skills using and troubleshooting telehealth
equipment and technology. Telehealth equipment must be used Nursing Consideration: Before each live videoconferencing
regularly to maintain proficiency, and confidence will grow with encounter, the nurse should test the connection with the
increased use. originating site by turning on the equipment, connecting to
the site, and testing the audio and visual quality between the
The telehealth nurse should be proficient at troubleshooting
sites.
issues that arise. In the case of troubleshooting without resolve,
Developing confidence and expertise in telepresenting
As with any new telehealth role, education and hands-on skill
building is essential. Both clinical and technology technical Self-Assessment Quiz Question #10
skills aligned to the nursing telehealth role serve to integrate Telehealth nursing proficiency relates to the skills,
telehealth into nursing. approaches, and communication strategies required to
practice at a distance. Nurses can draw upon their existing
Nursing Consideration: Nurse telepresenters can establish skill set as a foundation as they begin to build the unique
protocols for their telehealth program patient telepresenting set of skills required for the telehealth practice arena.
according to established national guidelines (ATA, n.d.). New competencies will be needed to effectively leverage
The use of HIPAA compliant technology and ensuring technology into everyday nursing practice.
adherence to laws and regulations guiding telehealth practice Which response best applies to telehealth competencies for
is part of the recommended protocols and guidelines for the registered nurse in the virtual practice environment?
telehealth practice. The nurse telepresenter should ensure a. Skills in telepresence are not needed as most nurses
a patient consent has been obtained, if needed. The nurse regularly FaceTime and have built up a repertoire of these
telepresenter should display active listening and assist with any new skills already.
b. Telehealth etiquette relates to the specific behaviors
communication clarification between the patient and provider. and skills that are displayed and used in the traditional
The skill set for the nurse telepresenter therefore includes encounter.
the following: effective communication skills (especially in the c. New knowledge and skills for the virtual practice arena
virtual environment), proficiency with telehealth technology, are needed to convey the essence of nursing: enabling
effective patient education about the disease process and transmitting and receiving presence and conveying
aspects of telehealth, and proficiency in telehealth etiquette. empathy in the virtual care environment.
d. Although nurses can utilize the technology to deliver
nursing care, proficiency using the technology is the
responsibility of the IT staff.
Conclusion
The future of telehealth is upon us. Health care is being communications and providing access to care. Additionally,
reinvented seemingly overnight through the use of advanced during epidemics and pandemics, telehealth enables remote
technologies. Telehealth provides endless opportunities to monitoring of quarantined or isolated patients and provides the
provide and enhance care through improving access, increasing ability to care for patients at a distance, mitigating patient and
positive patient care outcomes, reducing costs, and increasing health care provider exposure. Nursing contributes to telehealth
satisfaction. Defining telehealth and telemedicine provides practice through roles such as the telepresenter, telehealth
clarity on the scope and concepts involved in this paradigm of patient educator, remote monitor nurse, and telehealth school
care transition. As nurses gain understanding of basic concepts, nurse. As the nurse gains telehealth competency, it will allow
they can begin to apply telehealth to their nursing practice. confidence and competence in use of telehealth and ensure
Technologies including store-and-forward, videoconferencing, smooth transition of nursing practice to the virtual environment.
medical peripherals, remote monitoring, and videoconferencing Leveraging knowledge of the types of technology, benefits and
as important tools in telehealth delivery. Telehealth can barriers to care, service delivery systems, program basics, and
be used in all health care arenas, including the important ways of knowing in telehealth will enable actualization of the
role in emergencies and disasters, by way of improving role of the telehealth registered nurse.
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FUNDAMENTALS OF TELEHEALTH: REGISTERED NURSING PRACTICE

IN THE VIRTUAL CARE ENVIRONMENT
1. The correct answer is D. 2. The correct answer is B.
Rationale: Sonny has difficulty accessing the care he needs Rationale: Many barriers to telehealth relate to lack of
locally as specialty providers are not available in every area. funds to set up programs and purchase the technology.
Sonny often travels long distances to receive care and this is Additionally, reimbursement does not have parity to in-person
expensive and difficult for his family. Telehealth can enable visit reimbursement and is a significant barrier to the use of
Sonny to connect with his specialty provider locally, negating telehealth. Lastly, patient and provider trust and buy-in are
the need for three days of travel to receive care. Using live essential for successful telehealth outcomes. The other answers
videoconferencing, the provider can gain a quality assessment are incorrect because if a facility has telehealth established
of Sonny and have time to talk with him directly. Sonny will have with a larger medical center to provide service, this is a benefit;
the opportunity to see the provider and discuss any symptoms if providers are licensed in all adjacent states and they have
or concerns directly as well. Needed labs could be obtained funding to develop telehealth, this is a benefit; and if nurses are
remotely using technology and transmitted to his specialty educated to use telehealth and trust the technology, this too is
provider, so the provider would have recent physiological data. a benefit.
In this way, Sonny can easily connect with his provider for a
virtual care visit enabling ease of access and lowering cost of
care. It enables Sonny to receive care more frequently if needed,
improving his care quality. This results in a positive patient care
experience for Sonny. The other answers are incorrect since
specialty care is not always available locally for rural patients, the
cost of telehealth is not higher for the patient, and telehealth
remote monitoring does enable the patient to transmit
physiological data to the provider for the visit.
Rationale: When diagnostic or physiologic patient data is Rationale: Telehealth changes the paradigm of practice
needed at frequent intervals but the provider and patient with the tools of technology as it is a disruptive technology,
do not need to be together for the data collection, store- enabling advanced methods of communications and
forward technologies are an option. Store and forward is a engagement with patients at a distance. Nurses can reflect
type of asynchronous technology that enables data to be upon the new skills needed for virtual practice and rely upon
remotely collected by the patient and then transmitted to their existing foundation of practice, models of nursing,
the provider without patient-provider real time interaction. and methods of knowing nursing, knowing the patient, and
The other answers are incorrect since live videoconferencing knowing the technology in the traditional environment when
is synchronous; remote monitoring programs can use both considering the skills that will foster translation of nursing to
synchronous and asynchronous technologies; medical the virtual care environment. The other answers are incorrect
peripherals can collect both diagnostic data and physiologic since telehealth brings about a new way of practice that is
data. rapidly changing the nursing paradigm of care; it is possible
4. The correct answer is C. to know nursing in the virtual care area as telehealth is a tool
Rationale: The telepresenter is with the patient and prepares for nursing care delivery; although telehealth can provide
the patient for the virtual care visit; prepares the environment; equivalent care compared to traditional care, there are new
accesses the medical records and imaging reports/ images for questions that arise when translating nursing care to the virtual
the visit; and assists the remote provider with the virtual visit. care arena as well as new ethical and moral dilemmas related
The other answers are incorrect since the telepresenter is with to this new way of practicing.
the patient at the originating site instead of being at the remote 8. The correct answer is D.
site; the telepresenter can assist in patient physiological and Rationale: Nurses can reflect upon their existing knowledge
imaging data collection; and the telepresenter should ensure the and patterns of knowing in the traditional nursing care
technology is working for the virtual encounter. environment when critically evaluating issues that arise in
5. The correct answer is C. the virtual practice arena. The other answers are incorrect
Rationale: Remote monitoring enables the patient to obtain, since personal knowing relates to the nurse’s knowing rather
collect, and transmit physiological data to providers (from their than the patient’s knowing; videoconferencing telehealth
own homes or via mobile device or app) so that providers can technologies have audio and visual capabilities where use of
assess patient physiological trends and outliers more frequently senses such as sight is heightened; and moral dilemmas will
than otherwise possible using only in-person visits. The other arise with the use of technology.
answers are incorrect because remote monitoring is able to 9. The correct answer is B.
measure, obtain, and transmit biometric data; patient education Rationale: Telehealth microphones amplify soft sounds and
can be performed using remote monitoring technologies; remote background noises, so for achieving the best quality of audio,
monitoring can be used for monitoring of patient symptoms. muting your microphone if you are not speaking can help
6. The correct answer is D. prevent extraneous noises from being heard at the remote site.
Rationale: During national emergencies, rules for telehealth The other answers are incorrect since looking at the patient’s
may be waived by the federal government or by states (such image on the screen does not appear to the patient as if you
as occurred during the COVID-19 crisis) for some aspects are looking into their eyes—to do that you must look at the
previously causing barriers to telehealth use. Although the camera; nurses and providers should dress professionally for
Federal 1135 Waiver allows some private non-secure/HIPAA the virtual care encounter; telehealth encounters should not
compliant platforms to be used, the highest level of security take place in public settings.
platform should be chosen for use. So, although Nick can use 10. The correct answer is C.
Apple FaceTime, Facebook Messenger Video Chat, Google Rationale: New nursing knowledge and skills specific to
Hangouts Video, and Skype for telehealth visits, the best choice care in the virtual environment are needed to best translate
is to use a HIPAA compliant platform and to continue in the nursing presence and empathy during telehealth nursing
Interactive Monitoring Program using the secure equipment. care delivery. The other answers are incorrect because even
The other answers are incorrect since publicly accessible video though many people use FaceTime, the skills in the virtual
platforms such as FaceTime Live are not authorized for use in care environment are not regularly practiced in the social
telehealth; Nick should continue to use the secure technology setting; telehealth etiquette refers to skills and behaviors in the
platform used by the Interactive Monitoring Program since it virtual environment; nurses need proficiency and skills using
affords him the most safety related to private health information. telehealth technology in nursing practice.
Course Code: ANCCNC04FT22
Health Care Management of Patients with Substance Use Disorders
2 Contact Hours
Release Date: July 15, 2021 Expiration Date: July 15, 2024
Faculty
Author: Karen S. Ward, PhD, MSN, RN, COI, received BSN counseling. Dr. Wilson has a private practice as a holistic nurse
and MSN degrees in psychiatric-mental health nursing from and is an internationally known speaker on stress and self-care.
Vanderbilt University and a PhD in developmental psychology Dr. Wilson was named the 2017-2018 American Holistic Nurse
from Cornell University. She is a professor at the Middle of the Year. She is on the faculty at both Austin Peay State
Tennessee State University School of Nursing, where she has University School of Nursing and at Walden University.
taught in both the undergraduate and graduate programs. Debra Rose Wilson has disclosed that she has no significant
Dr. Ward’s work has been published in journals such as Nurse financial or other conflicts of interest pertaining to this course.
Educator, Journal of Nursing Scholarship, Journal of Emotional Reviewer: Cindy Parsons, DNP, ARNP, BC, is a Psychiatric
Abuse, and Critical Care Nursing Clinics of North America. She Mental Health Nurse Practitioner and educator. She earned her
has also presented her work at local, regional, and international Doctor of Nursing Practice at Rush University, Illinois and her
conferences. Dr. Ward’s research interests include child and Nurse Practitioner preparation from Pace University, New York.
adolescent maltreatment, mental health, and wellness issues Dr. Parson’s is an Associate Professor of Nursing at the University
(stress and depression), leadership variables, and survivorship. of Tampa and maintains a part-time private practice. She is
Karen S. Ward has disclosed that she has no significant board certified as Family Psychiatric Nurse Practitioner and a
financial or other conflicts of interest pertaining to this course. Child and Adolescent Psychiatric Clinical Specialist and her areas
Author: Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, of specialization are full spectrum psychiatric mental health care
CHT, received an MSN in holistic nursing from Tennessee State with a focus on family systems, community health and quality
University School of Nursing and a PhD in health psychology improvement. Dr. Parson’s currently
with a focus in psychoneuroimmunology from Walden University. serves as the chair of the QUIN council, is the membership chair
She has expertise in public health, psychiatric nursing, wellness, for the Florida Nurse Practitioner Network, and in 2009, she
and disease prevention. In addition to being a researcher, Dr. was inducted as a Fellow of the American Association of Nurse
Wilson has been editor of the International Journal of Childbirth Practitioners.
Education since 2011 and has more than 150 publications with Cindy Parsons has disclosed that she has no significant
expertise in holistic nursing, psychoneuroimmunology, and grief financial or other conflicts of interest pertaining to this course.
Course overview
Substance use disorder is widespread, varies from culture to outpatient programs, a multimodal treatment approach, possible
culture, and covers a vast array of mind-altering substances. pharmacological treatments, and behavioral therapy. This
The purpose of this course is to help health care workers course helps to prepare health care professionals to recognize
in their treatment of patients with substance use disorders, SUDs, suggest treatments, provide important motivation and
also called SUDs, and to provide patients with the tools and encouragement, and assist with self-management skills that will
interventions to pursue a lifestyle on their own absent from help with a successful recovery.
substance use disorder. The treatment for SUDs includes in- and
Learning objectives
Upon completion of the course, the learner will be able to do Compare the types of assessments used by healthcare
the following: professionals in the past to the more recent tool for assessing
Differentiate the common health care diagnoses for patients patients.
with substance use disorders. Distinguish four types of non-alcohol related substance use
disorder.
Apply appropriate interventions for patients who exhibit
signs of substance use disorder.
● Read the entire course online or in print which requires a ○ An affirmation that you have completed the
2-hour commitment of time. educational activity.
the course. ● Complete the MANDATORY Course Evaluation.
● Depending on your state requirements you will be asked to ● Print your Certificate of Completion.
complete either:
CE Broker reporting
Colibri Healthcare, LLC, provider # 50-4007, reports course Carolina, or West Virginia, your successful completion results will
completion results within 1 business day to CE Broker. If you be automatically reported for you.
are licensed in Arkansas, District of Columbia, Florida, Georgia,
Kentucky, Mississippi, New Mexico, North Dakota, South
Disclosures
course activity.
Disclaimer
Course verification
INTRODUCTION
Throughout history, societies have consistently found The most widely used illicit psychoactive substance in the United
substances that provide mind-altering properties. The specific States is Cannabis (NIMH, 2017). As of early 2017, cannabis was
substance that is used varies from culture to culture and over illegal under federal law and is still classified by the United States
time. Generally, norms are established as to what constitutes government as being equally dangerous as heroin. However,
acceptable use and what constitutes misuse. Using any state laws have changed to allow legal use of cannabis in over
substance in a non-socially accepted way is viewed negatively. 18 states (NCSL, 2021). Because there are both legal and illegal
The health care costs associated with illicit substance use markets for cannabis, health care professionals working in areas
disorder in the United States are $11 billion annually (National where they see patients affected by cannabis on a regular basis
Institute of Mental Health, [NIMH], 2017). Alcohol use disorder should become familiar with the typical strength and potential
is not included in these numbers, so the total cost is significantly contaminants in their area as well as their state’s laws regarding
higher. Cultural traditions surround the use of alcohol in family, use of this substance.
religious, and social settings. There are marked differences in Prescription drug abuse is a growing concern in the United
the quantity, frequency, and patterning of alcohol consumption States and does not appear to be easing up any time soon.
in different countries. Alcohol consumption is legal in the United Except for cannabis and alcohol, prescription drugs are the
States for persons older than 21 years of age. There is some most abused substances. In the U.S., an estimated 52 million
evidence that drinking small amounts of alcohol is beneficial for people have taken prescription drugs for a nonmedical reason
many people. However, the negative consequences that alcohol at least once. Prescription drug use disorder is an issue facing
use disorder has on relationships, finances, employment, and both young and older adults, and teens. The types of drugs
health are well known. that people commonly abuse include painkillers, stimulants, and
In the United States, many individuals use illicit substances such sedatives (Smith, 2021).
as cannabis, methamphetamine, cocaine, and heroin. Synthetic In every health care setting, health care professionals interact
heroin and heroin laced with fentanyl are popular substances. with patients who have substance-related disorders. For patients
Amphetamines are used by individuals at all levels of society and with a substance use disorder (SUD), the manner in which a
is more common among younger adults. health care professional cares for them is important. Those who
work in emergency departments are familiar with patients who use are less socially accepted than in the past, with increased
use substances. In some parts of the United States, cocaine, attention now being paid to the risks of secondhand smoke and
crack, and phencyclidine (PCP) have brought increased violence protecting nonsmokers (NIMH, 2017).
into the emergency department. Patients with substance-related Nurses may be the first health care professionals with whom
problems are seen on medical-surgical units and even maternity a patient with substance-related disorders comes in contact.
units, where mothers misusing substances give birth to babies Nurses may have the opportunity to intervene by providing
who experience the adverse effects of the substance or neonatal assessment, corroboration, referral, and collaboration with the
abstinence syndrome (i.e., withdrawal). patient and the members of the patient’s health care team and
Although this course does not focus on tobacco use, nicotine family. Getting an accurate substance use history is critical to
is considered an addictive drug, the consequences of which providing the best care for any patient.
can change and end lives. Smoking and other forms of tobacco
HEALTH CARE ATTITUDES
The health care professional can potentially have an impact on or patients with SUDs are particularly good at manipulating
influence the resistance of patients who are misusing substances. situations to receive more medication than necessary, and this
It is essential for health care professionals to examine their can make the health care team angry. Even when patients are
own attitudes and beliefs about people with SUDs before truly trying to stop their substance misuse, it can be difficult and
working with them. For example, it is helpful when health care involve a lot of treatment failures. Caring for patients with repeat
professionals understand and believe that SUDs are a legitimate admissions to the hospital may be annoying to health care
problem rather than a result of moral weakness. professionals who feel their time is better spent on patients who
It can be frustrating to care for patients with SUDs, and health are “really sick.” Patients who misuse substances are also sick in
care professionals may want to avoid them if possible. Many some way and need quality care.
SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

The general biopsychological process of addiction reward (Volkow et al., 2016). A decrease in the normal dopamine
involves substances that either mimic naturally occurring production in the brain (tolerance) may cause the person to
neurotransmitters or cause abnormally large amounts of feel depressed and to increase the behaviors that stimulate
neurotransmitters to be released. Specifically, these substances dopamine production (Volkow & Morales, 2015). Addiction is a
can cause sharp increases in the release of dopamine in the neurophysiological process and has been linked to more than
nucleus accumbens (Volkow et al., 2016; Volkow & Morales, smoking, drinking, or misuse of other substances. Food, sex,
2015). Conditioned learning occurs with repeated exposure, and and gambling addictions are recognized in the Diagnostic and
eventually the dopamine neurons stop firing in response to the Statistical Manual of Mental Disorders (5th edition; DSM-5).
actual reward and start responding to cues in anticipation of the
Diagnostic assessment and the DSM-5 psychiatric diagnoses
The DSM-5 diagnoses for patients with substance-related
Box 1. DSM-5 Substance-related Disorders and Diagnoses
disorders are divided into substance-use disorders and
substance-induced disorders (APA, 2013). As the term implies, Alcohol use disorder
substance-induced disorders (such as intoxication, withdrawal, • Alcohol intoxication
anxiety, and sleeping disorders) are the result of a patient’s • Alcohol withdrawal
substance use disorder. These conditions are generally Caffeine use disorder
considered to be temporary and based on the length of time the • Caffeine intoxication
substance’s effects last; it is assumed that once a person stops • Caffeine withdrawal
using these substance-induced disorders will disappear. The
focus of this course is to recognize and evaluate substance-use Cannabis use disorder
disorders related to alcohol, cannabis, hallucinogens, inhalants, • Cannabis intoxication
opioids, sedatives, hypnotics, anxiolytics, and stimulants (See • Cannabis withdrawal
Box 1). Other hallucinogen use disorders
• Other hallucinogen intoxication
• Inhalant use disorder
• Inhalant intoxication
Opioid use disorder
• Opioid intoxication
• Opioid withdrawal
Sedative, hypnotic, or anxiolytic disorder
• Sedative, hypnotic, or anxiolytic intoxication
• Sedative, hypnotic, or anxiolytic withdrawal
Stimulant use disorder
• Stimulant use intoxication
• Stimulant use withdrawal
Tobacco-related disorders
• Tobacco use disorder
• Tobacco withdrawal
• Other tobacco-induced disorders
(American Psychiatric Association, 2013)
HEALTHCARE DIAGNOSES
Numerous healthcare diagnoses are possible for patients with ● Spiritual distress, risk; readiness for enhanced
substance-related disorders. Patients with these disorders Healthcare diagnoses that are related to the potential
commonly have more than one healthcare diagnosis such as the physiological result, or sequelae, of substance-related disorders
following (Herdman & Kamitsuru, 2018): include the following (Herdman & Kamitsuru, 2018):
● Coping (e.g., ineffective, readiness for enhanced, ● Activity intolerance
compromised family) ● Anxiety (e.g., moderate, severe, panic)
● Family processes (e.g., dysfunctional, interrupted, readiness ● Altered nutrition
for enhanced) ● Disturbed sleep pattern
● Denial (ineffective) ● Self-care deficit (e.g., bathing, dressing, feeding)
● Self-esteem (e.g., chronic low, risk for low) ● Memory, impaired
● Confusion (e.g., acute, chronic) ● Sexual dysfunction
● Decisional conflict
● Violence, risk for other-directed or self-directed
ALCOHOL-RELATED DISORDERS
Alcohol use disorder is the excessive use of beverages States live in a home where a parent has alcohol problems
containing ethanol. Alcohol use disorder is recognized as an (NIAAA, 2017). There is an enormous cost of preventable death
addictive disease that changes brain circuitry and thus function. associated with alcohol use disorder.
Chronic exposure to alcohol causes the balance of chemicals in Recent data on alcohol use disorder reveal that an estimated
the brain to change, resulting in an increased craving for alcohol 15.1 million U.S. adults describe themselves as having a
(NIAAA, 2017). problem with alcohol, and 1.3 million have received some sort
The National Institute on Alcohol Abuse and Alcoholism, or of treatment. For children younger than 17 years, 2.5% met the
NIAAA, reports that 86.4% of adults over 18 years of age have criteria for alcohol use disorder (NIAAA, 2017). A combination
consumed alcohol, and 56% have consumed alcohol in the of physical, psychological, and social factors seems likely to
past month. Alcohol use disorders include binge drinking and contribute to the development of alcohol-related disorders in
long-term alcohol use. More than 10% of children in the United the context of each person’s life (See Table 1).
Table 1. Factors Associated with the Development of Alcohol-Related Disorders

Factors Alcohol-Related Disorders
Physical Factors • Because a high rate of alcohol use disorder is seen in families, a genetic link cannot be ruled out.
When a choice is made to drink, that choice may have been influenced by the environment. However,
once a person is drinking regularly, there are genes that more easily trigger the brain to further use the
substance (NIAAA, 2017).
• An endocrine dysfunction may cause a desire for or a predisposition to use alcohol.
• A nutritional theory claims that some deficiencies may cause a craving for alcohol.
Psychological Factors • Extreme need for oral gratification.
• Ineffective coping skills.
• Low self-esteem.
• Repeated drinking over time that results in relief of tension.
• Presence of other psychiatric disorders, such as depression and anxiety, is also associated with a
greater likelihood of alcohol use disorder.
Social Factors • Having a partner or spouse who drinks regularly.
• Excessive drinking because of patterns in the family.
• Experiencing disrupted family life and relationships.
• Being “socialized” within the family or having access to alcohol within the neighborhood.
• Adolescents who have friends who drink are more likely to drink themselves.
• In addition, some cultural and ethnic groups drink more than others do, and more men than women
have alcohol use disorders, although the number of women with the disorder is increasing.
• Many media messages glamorize drinking.
(Halter, 2018; National Institute on Drug Abuse [NIDA], 2020; Townsend & Morgan, 2017)
Screening for alcohol use disorder

Assessments should be made of all patients, considering If yes, ask: When was the last time you had four (women) or five
possible misuse of alcohol or other substances and the resulting (men) or more drinks in 1 day?
social problems (e.g., marital, work-related, or legal, including Within the past 3 months is a positive screen. This would suggest
drunk driving or arrests for assault). Physical illnesses, such as that a more detailed assessment of alcohol consumption and its
liver, gastrointestinal, and neurological problems, and recurrent consequences should be done.
injury may be associated with the coexistence of alcohol use
disorder. Emotional problems, such as depression, insomnia, and A more recent tool for assessing alcohol and substance use
irritability, can also be associated with alcohol use disorder. includes screening as well as brief intervention and referral to
treatment. A format for brief interventions, which has been
An assessment of alcohol use includes the amount and researched and is effective, is focused on stating concern, offering
frequency of alcohol consumption and any evidence of the advice, gauging readiness to change behavior, requesting that
presence of alcohol withdrawal symptoms. A brief screening the patient reduce consumption if not ready to enter abstinence-
of all patients can be completed using the following resources focused treatment, providing educational materials, and helping
(American Psychiatric Association, 2013; SAMHSA, n.d.). the patient find treatment (SAMHSA, n.d.).
Ask: Do you drink alcohol?
Case study 1
Richard Ellis was admitted to the local hospital for minor foot
surgery. He is 45 years old and appears to be in good physical Self-Assessment Quiz Question #1
shape. He is friendly with Kathy, the health care professional who
What should Kathy do at this point?
is there to do his admission screening, and frequently includes
a little joke along with his answers. As a routine part of the a. Stop the interview because Richard is not answering the
assessment, Kathy includes a brief alcohol use question: “Do question.
you drink alcohol?” Richard answers with “Oh, not really.” When b. Ask, “Why are you refusing to answer me in a
Kathy tries to clarify, Richard seems to become vaguer. straightforward manner?”
c. Explain that she needs this information to give him the best
care.
d. Say, “Mr. Ellis, I really need for you to stop joking around;
this is important.”
Case study 2
Richard seems to understand that Kathy is serious about getting Another brief assessment tool is the CAGE questionnaire (Ewing,
an answer to her question, and he answers that he does drink 1970). The CAGE questionnaire poses the following questions
alcohol on occasion. Kathy then asks how much he drinks in once it has been established that the individual is currently
a day, and Richards says that he drinks maybe two beers. Her drinking alcohol (SAMHSA, 2021):
next question is “When was the last time you had five [had she ● Have you ever felt you should Cut down on your drinking?
been interviewing a woman, she would have used four] or more ● Have people Annoyed you by criticizing your drinking?
drinks in 1 day?” If he answers, “within the past 3 months,” then ● Have you ever felt bad or Guilty about your drinking?
it is a positive screen. This would suggest that a more detailed ● Have you ever had a drink first thing in the morning to steady
assessment of alcohol consumption and its consequences should your nerves or get rid of a hangover (Eye opener)?
be done.
Kathy asks the questions from the CAGE questionnaire. What
Which answer by Richard would indicate that no further should she do with the results?
screening is needed? a. Make a note on Richard’s medical record.
a. “Gosh, I guess it must have been at one of my fraternity b. Warn Richard that he needs to control his drinking.
parties in college.” c. Ask the team leader to tell the next shift.
b. “Well, I’m not sure I can remember exactly when I had that d. Either call or leave written details of her findings with the
much at once.” primary health care provider or surgeon.
c. “Last weekend with my poker buddies – you know how
that goes!”
d. “It would have been a couple weeks ago when the wife
and I celebrated our anniversary.”
Effects of alcohol
Alcohol is the most pervasively misused substance. It is classified to heart disease, stroke, cancer, liver and pancreas diseases, and
as a central nervous system (CNS) depressant (NIAAA, 2017; generally poor decision making.
Townsend & Morgan, 2017). The early signs and symptoms of The effects of alcohol are different in each person. Some of the
intoxication, such as giddiness, talkativeness, and relaxation, effects are related to each person’s absorption time, which can
result from the alcohol’s depression of the person’s self-control be affected by variables such as the following (NIAAA, 2017;
system; inhibitions are diminished. Alcohol’s effects may seem Partnership to End Addiction, 2017; SAMHSA, n.d.):
socially appealing, but continued use can result in serious ● Amount of alcohol consumed
physiological, psychological, and social consequences. Even ● How quickly the alcohol is consumed
short-term drinking has consequences to an individual’s health. ● Gender, age, body weight, height, and general size
Immune function is reduced for up to 24 hours after alcohol ● Presence or absence of food in the stomach
consumption (NIAAA, 2017). Drinking too much alcohol is linked ● Stomach emptying time and metabolic rate
● Tolerance level
Alcohol use disorder
Alcohol use disorder is a progressive disease that can be fatal. emergency department for treatment of the alcohol-related
A number of physiological problems and potential diseases problem or because of other health-related issues. The presence
are related to excessive drinking. Table 2 outlines some of the of these problems may provide a clue to a patient’s as-yet-
physical complications associated with alcohol use disorder. unrecognized alcohol use disorder.
Patients who have these problems may initially show up in the
Table 2. Alcohol-Related Physical Complications Alcohol misuse refers to patterns of alcohol use with the
continuation of drinking despite marital discord, job loss threats,
System or Organs Involved Complication or legal and physical problems. An example of someone who
misuses alcohol is a person who continues to drink and drive
Brain, nervous system • Peripheral polyneuritis despite repeated convictions for driving under the influence of
• Wernicke-Korsakoff syndrome alcohol (American Psychiatric Association, 2013).
(disorientation, delirium,
Alcohol use disorder is diagnosed based on the use of quantities
confusion, confabulation,
of alcohol that are progressively larger than intended, the
ocular impairment; a
persistent desire to cut down or control use, craving, and
progressive disorder
continued use despite awareness of problems associated with
that requires thiamine
the consumption of alcohol, including a withdrawal syndrome
replacement)
(NIAAA, 2017; SAMHSA, n.d.).
Liver, pancreas • Alcoholic hepatitis The progressive course of alcohol use disorder can range from
• Liver failure mild signs and symptoms of hangover, missing or being late
• Pancreatitis to work, and some marital discord to severe symptoms of total
craving and dependence on alcohol. Alcohol dependence may
Muscular • Myopathy
be associated with a complete breakdown in the family, loss of a
Cardiopulmonary • Enlarged heart job, poor health, hospitalization for medical illnesses associated
• Susceptibility to infections with chronic alcohol ingestion, and signs and symptoms of
• Pneumonia withdrawal or intoxication.
Significant clues in the assessment of possible alcohol use
Gastrointestinal • Gastric distress disorder include the following (Halter, 2018; Townsend &
• Ulcers Morgan, 2017):
• Nutritional imbalance ● A loss of control over drinking: sneaking drinks, drinking until
Cardiovascular • Anemia unconscious, drinking in the morning
● Social and occupational problems: arguing about drinking
Based on Halter, M. J. (2018). Varcarolis' foundations of psychiatric men- with spouse and other family members, missing work
tal care: A clinical approach (8th ed.). Elsevier. because of drinking or being hung over, not keeping
National Institute on Alcohol Abuse and Alcoholism. (2017). Alcohol and engagements, becoming unreliable
your health. ● Blackout episodes: continuing to function but having no
recall of events
https://www.niaaa.nih.gov/alcohols-effects-health/alcohols-effects-body ● Legal complications: being convicted of driving under the
National Institute of Mental Health. (2017). Trends and statistics in influence of alcohol
substance use disorder. https://www.drugabuse.gov/related-topics/
trendsstatistics
Townsend, M., & Morgan, K. I. (2017). Essentials of psychiatric mental
care: Concepts of care in evidence-based practice (7th ed.). F. A. Davis.
Alcohol intoxication
People who are intoxicated are usually not difficult to recognize. ● Incoordination and ataxia
After recent ingestion of alcohol, they generally display some ● Nystagmus
or all the following (NIAAA, 2017; Partnership to End Addiction, ● Impaired judgment
2017; SAMSHA, 2017): ● Decreased inhibitions, aggressiveness, and increased sexual
● Odor of alcohol on the breath impulses
● Emotional lability, ranging from euphoria to hostility ● Memory or attention impairment
● Slurred speech ● Stupor or coma
Alcohol withdrawal
In a general hospital setting, a patient can have undiagnosed
alcohol use disorder and receive treatment for a health problem Box 2. Signs and Symptoms of Alcohol Withdrawal
that might be related or unrelated to it. Because patients • Autonomic hyperactivity
ordinarily cease drinking immediately upon admission or shortly • Increased hand tremors
before, health care professionals must be aware of the signs and • Tachycardia
symptoms of alcohol withdrawal (see Box 2). • Psychomotor agitation
• Anxiety
• Nausea
• Vomiting
• Insomnia
• Grand mal seizures
• Transient, visual, tactile, or auditory hallucinations or
illusions
• DTs
Based on Halter, M. J. (2018). Varcarolis' foundations of psychiatric men-
tal care: A clinical approach (8th ed.). Elsevier.
Townsend, M., & Morgan, K. I. (2017). Essentials of psychiatric mental
care: Concepts of care in evidence-based practice (7th ed.). F. A. Davis.
Withdrawal from alcohol generally occurs 24 to 72 hours after Potential Complications of Alcohol Withdrawal
the last drink was consumed (MedlinePlus, 2017. It should be
noted that people who habitually consume large quantities of • Aspiration pneumonia
alcohol daily, and thus have developed tolerance, can function • Peripheral vascular collapse
reasonably well, even with a high blood alcohol level. These • Seizures
individuals may also experience symptoms of withdrawal if • Hyperthermia
they are not maintaining their accustomed extremely high • Infection
blood alcohol level. During withdrawal, the patient’s health • Myocardial infarction
progressively deteriorates. Potential complications of alcohol • Self-inflicted trauma, purposeful or accidental
withdrawal are listed in Box 7-3. • DTs
• Death because of one of the other complications
Health Care Consideration: When patients are admitted
in an unconscious state and require surgery, the health Based on Halter, M. J. (2018). Varcarolis' foundations of psychiatric men-
care professional should be alert for possible withdrawal tal care: A clinical approach (8th ed.). Elsevier.
symptoms beginning after the recovery period. Because CNS Townsend, M., & Morgan, K. I. (2017). Essentials of psychiatric mental
depressants act cumulatively in the body, it is possible for care: Concepts of care in evidence-based practice (7th ed.). F. A. Davis.
someone with a long history of drinking to be given various If patients have used alcohol in significant quantities over a long
medications for surgery and the immediate postoperative period of time, withdrawal can become life-threatening. DTs can
period and then develop withdrawal symptoms once those be part of the withdrawal process, causing extremely dangerous
medications are discontinued. In effect, the sedatives and pain symptoms such as marked autonomic hyperactivity (tachycardia,
medications have stabilized the patient throughout the initial sweating, fever, anxiety, and insomnia) and vivid visual and tactile
hospitalization. In effect, they have kept the patient “drinking.” hallucinations (Halter, 2018). Once a person has had DTs during
It is only after these medications are stopped that withdrawal withdrawal, it is quite likely that DTs will occur again during any
may begin. For this reason, it is worthwhile for the health care subsequent withdrawal episode. This is a medical emergency
professional to get a substance use history even if the patient and can result in death (Townsend & Morgan, 2017).
has been in the hospital for a while.
Specific treatment for alcohol-related disorders
The immediate treatment for current withdrawal symptoms with the issues surrounding the alcohol use disorder of a family
or impending DTs is pharmacological. An antianxiety agent, member.
usually a benzodiazepine, is used. The CNS depressant action Public and private outpatient programs are available through
of the drug helps minimize progression of the withdrawal. The clinics and private practitioners from a variety of disciplines,
benzodiazepine can then be titrated down gradually to the including physicians, health care professionals, social workers,
lowest effective dose until the patient is no longer at risk for psychologists, drug and alcohol counselors, and other health
serious sequelae of withdrawal. Eventually, the medication can care professionals. These programs may be oriented to the
be discontinued. Additional symptomatic treatment is also group or individual. Some offer residential treatment and then
provided as needed. outpatient follow-up care.
Other health issues to be considered are the patient’s nutritional Use of medications after the withdrawal period has been
status, including fluid and electrolyte balance and levels of effective for some people. Acamprosate, naltrexone, and
vitamins, in particular, thiamine and magnesium. The potential disulfiram are used to assist patients who cannot achieve
for trauma or self-harm should be addressed as appropriate. sobriety independently. The medications are antagonists to
Obviously, any imminent crisis (e.g., circulatory, or respiratory alcohol, and patients find that taking one of them is enough of
collapse) must be attended to immediately. a deterrent to maintain abstinence. However, the benefits of
When the immediate effects of alcohol withdrawal are subsiding, this treatment are eliminated if the patients have no motivation
the ongoing treatment for alcohol use disorder as the primary for taking the antagonist. Patients must be fully educated
disease problem needs to be considered. Most treatment and in agreement with this method because there are serious
programs in the United States are based on the idea of the consequences related to taking them and consuming alcohol
“recovering” alcoholic (Townsend & Morgan, 2017). These in any form (including mouthwash, some salad dressings, and
treatment programs advocate taking one day at a time and alcohol-based products such as hand sanitizers; NIH, 2016;
accepting the ideas that the temptation to drink is ever-present NIDA, 2019).
in society and that abstinence is the only way to maintain Each person’s situation, general health, emotional problems,
sobriety. amount of physical disease, and life circumstances should be
Because the causes of alcohol use disorder differ from person considered when recommendations for treatment are made. It
to person, a wide range of treatment approaches are needed. may be preferable for the person with an alcohol use disorder to
Self-help groups including Alcoholics Anonymous are available, receive treatment as an inpatient, removed from the pressures
as well as family and marital therapy (which can be an important and commitments of everyday life and from the access to
adjunct as well), individual therapy, education programs, alcohol, in a place where treatment can be intensive. Conversely,
behavioral therapy, and aversion therapy. being an inpatient may jeopardize a person’s job, family, or social
A variety of treatment options are available. Inpatient programs situation, and, thus, beginning treatment as an outpatient might
are found in general hospitals, psychiatric hospitals, residential be a better option (SAMHSA, n.d.). Many insurance companies
treatment facilities, and group homes. Outpatient treatment can require outpatient treatment rather than inpatient hospitalization
be provided through privately owned businesses or through the unless the patient is experiencing severe medical or psychiatric
auspices of clinics, hospitals, or other public facilities. Of the issues that could be life-threatening.
outpatient programs, Alcoholics Anonymous is the most well- Contemporary treatment of alcohol use disorders is a
known and widely used. It is free, anonymous, and supportive. multisystem effort. Programs include a variety of approaches
Since the 1940s, it has been a growing, popular, and respected (Halter, 2018; Townsend & Morgan, 2017). A patient’s treatment
12-step self-help program. Because alcohol use disorder has plan may include any or all the following:
effects on all members of a family, Al-Anon and Alateen are ● Individual counseling
groups that are available for family members to help them cope ● Group therapy
● Daily educational meetings
● Family therapy the open. Treatment options are available to all who want
● Occupational therapy or vocational rehabilitation help. The biggest concern is getting the person who is abusing
● Recreational therapy alcohol into treatment. It is thought that the life expectancy of
● Psychopharmacological therapy individuals who have a problem with alcohol and do not stop
The increasing problem of alcohol use disorders and increased drinking will be decreased by an average of 15 years (NIAAA,
awareness of it by the medical community and the media have 2017; Partnership to End Addiction, 2017; SAMSHA, 2017).
brought the “secret” of widespread alcohol use disorder into
NONALCOHOL SUBSTANCE USE DISORDERS
Like alcohol use disorder, use disorders of other substances Risk factors for substance use disorder include family history,
has no single, known causative factor. Substance use disorders being male, having another psychiatric disorder, peer pressure,
seem to manifest in a person who is experiencing a combination lack of positive coping skills for mediation of emotions, lack of
of biological, psychological, and social phenomena. Genetic family involvement, and use of highly addictive substances such
predisposition and environment play contributing roles in the as opioids or cocaine (Halter, 2018; Townsend & Morgan, 2017).
development of substance use disorder. Society has been In view of the different substances readily available, it is no
medically and commercially socialized to “pop” pills: “Have a surprise that polysubstance use disorder (abusing more than
headache, toothache? Take a pill.” Children are raised in this one substance at a time) has become a problem. Although
atmosphere. all the substances used are associated with some degree of
Young people often begin abusing substances because of psychological dependence, some are physically addicting.
peer pressure (NIDA, 2019. During the vulnerable preteen and Continued use creates a physical tolerance and a craving for
adolescent years, some individuals begin taking drugs to be part the substance. Discontinuing their use causes a great deal
of the crowd. Some adolescents may be rebelling against their of physical discomfort, so much so that the need for the
parents, other authority figures, and society itself. Others may be substance is heightened. Opioid addiction is an example of this
looking for an escape from their perceived problems and feelings phenomenon.
of depression. These children are looking for a way out of their Many researchers are dissatisfied with the inconclusiveness of
present reality. psychosocial theories of substance use disorder and are focusing
Once substances are tried, different variables come into play that their attention on biochemical factors. Substance use disorder is
determine whether a person develops a substance use disorder. still explained best by a biopsychosocial model that combines
These include a person’s place in society, self-esteem and self- multiple factors.
concept, age, peers, finances, lifestyle, personality characteristics, Heroin has long been a substance associated with use disorders.
and other physical and emotional problems. The environment also In the 1960s, cannabis, lysergic acid diethylamide (LSD), and
plays a role, particularly if the individual has repeated exposure to other psychedelic drugs were the popular substances of choice.
stressors such as poverty, racism, lack of appropriate educational The use of “downers” (barbiturates and tranquilizers) and
and job opportunities, frequent exposure to drug sales and drug prescribed medicine followed. In the 1970s, “uppers” came
use, and absence of protective relationships and positive activities. to the forefront, along with PCP (NIMH, 2017; United Nations
Abuse of medicines may start with a medication prescribed for Office on Drugs and Crime, 2016). The 1980s brought the
a defined ailment. However, use can quickly become a physical cocaine crisis, along with crack and crystal methamphetamine
dependence. Individuals of all ages are abusing and sharing (crystal meth), and a peak in substance use. In the 1990s,
prescription drugs without regard to the uses for which these younger age groups entered the drug-using community, and
drugs were initially intended. research efforts focused on determining causative factors for all
forms of substance use disorders. All the previous issues related
Evidence-based practice! Individuals in need of treatment for to substance use disorder have continued into the 2000s, with
alcohol use disorder are often very willing to go into treatment the opioid epidemic getting the most attention (NIMH, 2017).
immediately after an experience with withdrawal, particularly if
it is not the first time, and they have gone through DTs. Once Any patient who is physically dependent on one or more
sober and out on their own, however, it is difficult for them substances and is currently hospitalized is at risk for withdrawal.
to remain sober. Much effort goes into trying to find “the” Many times, information about drug use is not available; either
treatment that will make it easier to obtain sobriety and remain patients are not willing to provide it, or they are unable to do
sober. An interesting study was conducted using virtual reality so because they are unconscious. Sometimes the withdrawal is
(Sharma et al., 2019). In this research, subjects were shown delayed because similar drugs have been used during treatment.
what effects alcohol has on their bodies using virtual reality.
At least in the short term, having the opportunity to visualize For example, as noted earlier, someone using CNS depressant
and experience intoxication while sober seems to show some drugs will not go through withdrawal if given other CNS
promise in helping patients maintain sobriety. Of course, much depressants for surgery or pain relief.
more study is needed, but these early results seem worth
pursuing.
Cannabis-related disorders
Recreational cannabis and hashish generally produce a state of Cannabis intoxication includes the following signs and symptoms
mild euphoria and relaxation. These substances are smoked in a (American Psychiatric Association, 2013; SAMHSA, n.d.):
“joint” (a hand-rolled cigarette) or through a pipe. They can also ● Maladaptive behavior or psychological changes, such
be cooked in food and ingested in that manner. Hallucinations as impaired motor coordination, euphoria, anxiety, and
can occur with high doses. Lack of motivation and possible impaired judgment
irreversible brain damage have been matters of concern in ● Conjunctival injection
adolescents who smoke cannabis extensively (SAMHSA, n.d.). ● Increased appetite
● Dry mouth
● Tachycardia
Hallucinogen-related disorders
The hallucinogens LSD, PCP, psilocybin (magic mushrooms), quantities of natural substances) are drugs that alter a person’s
mescaline (from cacti), and the more recent kratom, “bath salts” sense of reality and consciousness. They cause a distorted sense
(synthetic), or “spice” (as manufactured substance or large of energy and excitement. Hallucinations and other perceptual
changes may occur. LSD was popularized as “acid” in the hippie symptomatic treatment, the most common method of helping
era of the 1960s. In the 1970s, PCP or “angel dust” was more patients experiencing bad effects because of hallucinogenic
commonly used. Violent side effects are associated with the use agents is to “talk them down.” This is done in a calm, reassuring
of PCP. Each generation seems to find its own favorite way to tone, reminding patients that they have taken something that is
escape reality. People who use these drugs can become quite causing the bad experience, responding to their questions, and
paranoid and delusional and act out impulsively. Personnel in generally trying to get them to interact within the reality of their
the emergency department often have been assaulted while situation rather than the hallucinatory experience.
attempting to administer care to such patients. Apart from
Inhalant-related disorders
Sniffing glue or inhaling other substances such as paint, paint substances are seen as a “cheap high” in this school-age group
thinner, gasoline, or even correction fluid (Liquid Paper) is a less and may cause not only social and school problems but also
common problem than other forms of drug use. Children and respiratory and neurological damage (Nguyen et al., 2016).
preteens are more apt to have an inhalant use disorder than Although readily available and comparably inexpensive, these
people in other age groups probably because the substances are dangerous drugs.
are cheap and readily available. Inhalants and some other
Opioid-related disorders
Heroin, methadone, and narcotics such as morphine and The signs and symptoms of withdrawal from opioids are
meperidine have long been known for their addictive properties (American Psychiatric Association, 2013; Townsend & Morgan,
and their definite and severe withdrawal patterns. Today, the 2017):
opioids of choice for many people include the prescription ● Dysphoric mood
medications acetaminophen, hydrocodone, and oxycodone. ● Nausea and vomiting
Ironically, a medication developed to treat addiction to opioids, ● Muscle aches
buprenorphine, and naloxone, has also increased in “street” use. ● Lacrimation or rhinorrhea
Abused for their euphoric properties, these drugs also produce ● Pupillary dilation, piloerection, or sweating
pain relief, apathy, and impaired judgment. Patients with opioid ● Diarrhea
use disorders, such as heroin use, seem to be seeking release ● Yawning
from daily woes (SAMHSA, n.d.). ● Fever
The signs and symptoms of opioid intoxication and overdose are ● Insomnia
(American Psychiatric Association, 2013; Townsend & Morgan,
2017): Evidence-based practice! A recent study (McCauley et al.,
● Decreased respiration 2020) investigated whether dentists in rural areas prescribed
● Pinpoint pupils opioid medication for their patients as often as dentists in
● Pale, cool, clammy skin with cyanotic tinge larger cities. According to findings in this research, they do.
● Needle tracks (marks) on the arms and legs or in areas of The dentists in rural areas reported that opioid use disorder
hidden veins was a significant problem with their population, much more
● Cardiac dysrhythmias so than what was reported by dentists in urban areas. The
● Clouded consciousness, semi-comatose states, or coma researchers concluded that more education for practitioners in
● Pulmonary edema rural areas is needed to help them deal more effectively with
● Shock patients and their need for pain relief.
● Death as a result of respiratory failure or cerebral edema
Sedative-, Hypnotic-, and anxiolytic-related disorders
Sedatives, hypnotics, and anxiolytics such as benzodiazepines (American Psychiatric Association,2013; Townsend & Morgan,
are in a group of tranquilizing drugs that cause quiescence, 2017)
relaxation, and a decrease in tension and anxiety (Townsend & The signs and symptoms of withdrawal from sedatives,
Morgan, 2017). Still prescribed medically and valuable for their hypnotics, and anxiolytics are:
beneficial effects, these drugs are highly misused. Tolerance ● Autonomic hyperactivity
often develops, causing the need for increases in dosages ● Increased hand tremors
and frequency of use. If outright addiction does not occur, ● Insomnia
habituation and dependence are common (Townsend & Morgan, ● Nausea and vomiting
2017). ● Transient visual, tactile, or auditory hallucinations
The signs and symptoms of misuse of sedatives, hypnotics, and ● Psychomotor agitation
anxiolytics are: ● Anxiety
● Clouded consciousness ● Grand mal seizures
● Hypersomnia (American Psychiatric Association, 2013; Townsend & Morgan,
● Coma 2017)
Stimulant-related disorders
Amphetamines The signs and symptoms of amphetamine misuse include:
Amphetamines are CNS stimulants. They have been used ● Euphoria
to treat obesity, attention-deficit/hyperactivity disorder, and ● Hyperalertness
narcolepsy. However, they are generally avoided, when possible, ● Anorexia
because of their high potential for misuse (Townsend & Morgan, ● Increased pulse rate
2017). Amphetamine withdrawal develops within a few hours to ● Increased blood pressure
several days after cessation (or reduction) of amphetamine use ● Insomnia
that has been heavy or prolonged. ● Excessive talkativeness
(SAMHSA, n.d.)
The signs and symptoms of amphetamine withdrawal include: The signs and symptoms of cocaine overdose include:
● Dysphoric mood ● Panic level of anxiety
● Fatigue ● Increased pulse rate
● Vivid, unpleasant dreams ● Increased blood pressure
● Insomnia or hypersomnia ● Dilated pupils
● Increased appetite ● Severe perspiration
● Psychomotor retardation or agitation ● Syncope
(SAMHSA, n.d.) ● Seizures
Cocaine ● Episodes of delusions, paranoia, hallucinations, and mania
Cocaine seems to have been the scourge of the 1980s, and its ● Death, usually because of cardiac or respiratory failure
use is considered a stimulant use disorder. When cocaine use The signs and symptoms of cocaine withdrawal include:
disorder first became widespread, it was considered a white- ● Dysphoric mood
collar problem. The drug was expensive, and initially addiction ● Vivid, unpleasant dreams
and withdrawal problems were not seen. A fast-acting but short- ● Fatigue
lasting CNS stimulant, cocaine produces a rush of euphoria. The ● Hypersomnia or insomnia
popularity of “coke,” as it is commonly known, has continued, ● Psychomotor retardation or agitation
and spread. The drug has found its way into poorer communities ● Increased appetite
as crack cocaine, a cheaper, less pure, and smokable form of the (Halter, 2018; Townsend & Morgan, 2017)
substance. Cocaine addiction has increased since the 1980s.
TREATMENT APPROACHES
Patients with substance-related disorders generally cannot forces – job, family, money, and health – can contribute to their
achieve a substance-free lifestyle on their own. Because of the decision, an individual with substance use disorder needs to
craving, cost, peer-group pressure, and increased need for want to quit. Along with the desire to become substance-free,
the legal or illegal substance, continued use can cause serious help and support from others are extremely important.
damage in the person’s life. Family, friends, job relationships, the The single most predictive criterion for success or failure for
community, and society at large may all be affected adversely. all individuals with substance-related disorders is the level of
As with alcohol use disorder, treatment for a substance use motivation or lack of it. When motivation is high, a degree of
disorder ideally should be self-motivated. Although outside recovery usually can be achieved (NIDA, 2018).
Psychopharmacological treatment
Psychopharmacological treatment is generally used for lorazepam) are used for withdrawal from sedatives, hypnotics,
detoxification in emergencies (as antagonists) and for stimulants, and anxiolytics. Occasionally, the misused substance
maintenance therapy. Naloxone acts as an immediate antagonist is given in decreasing doses until the substance is no longer
to combat opioid overdose and is available even to people necessary. Often the treatment consists of supportive medication
outside the medical profession (causing a degree of controversy). for symptoms that the patient is experiencing. These drugs
Methadone is used for ongoing treatment of opioid use. For are only as useful as the patient makes them; following the
any substances of abuse associated with a physical withdrawal treatment plan is essential to success, and any treatment must
syndrome, psychopharmacological treatment is available to help be individualized for each person.
patients withdraw safely. Benzodiazepines (e.g., diazepam and
Inpatient and residential programs
For some patients, it is crucial for them to be away from the the approach that appears to best meet their specific needs
environment, place, or people in which or with whom they use is something health care professionals can do if reasonably
their substances of choice to gain freedom from dependency. informed about what is available.
Others have more success by maintaining their usual activities, Outpatient programs, federally funded methadone clinics,
and they find outpatient programs a better option. consumer-run programs, and private practitioners, including
In conjunction with a person’s general physical condition and advanced practice health care professionals, also offer
state of mind, the substance use disorder itself may be a factor many treatment services for persons with substance-related
in determining the best type of treatment. Some emergency or disorders. These include the following:
acute medical care may be needed, either for an overdose or ● Individual therapy
for potential sequelae of withdrawal. Certain hospitals, clinics, ● Group therapy
and private residential treatment facilities offer a wide range of ● Family and marital counseling
services, from withdrawal treatment to long-term rehabilitation. ● 12-step anonymous groups
Others offer only some of these services. Helping patients select ● Self-help recovery groups
Recovery
Recovery is not necessarily a one-time event. It is common for remain abstinent, repeated failures should not be criticized. An
relapses to occur. Therefore, patients may have to try repeatedly. attitude of acceptance and willingness to support abstinence
Even though an individual with substance use disorder may not and maintain a substance-free lifestyle should be fostered.
HEALTH CARE INTERVENTIONS FOR PATIENTS WITH SUBSTANCE USE DISORDERS
There are many independent health care interventions that can Withdrawal from any substance is a frightening experience for
be useful for patients with substance use disorders. The first step the patient. Depending on which substance the patient has
is to create a therapeutic relationship with the patient. Once the been using, as well as how much substance the patient has been
health care professional gains the patient’s trust, it is much easier taking and over how long a time the use has been occurring,
to obtain full cooperation with the treatment plan. It is most withdrawal can even be life-threatening. Without appropriate
important to provide the patient with a safe environment, both observation and intervention, patients can die if the substance
physically and emotionally. is abruptly discontinued. Nurses play a key role in obtaining a
thorough substance use history and in observing the patient for
severe signs and symptoms of withdrawal.
Once patients have been withdrawn from their substance of use for coping with the burdens of everyday life. The health
choice, it is important to get them into further treatment as care professional can educate the patient to recognize early
quickly as possible. Long-term recovery is highly unlikely without signs of stress buildup and what to do before it becomes
some form of rehabilitation follow-up. Nurses can educate overwhelming. Patients with any of the substance-related
patients about the substances, why their misuse is problematic, disorders are in the habit of self-medicating rather than coping
and provide appropriate referrals and resources that are in some other, less harmful way. Helping patients learn more
available in their community. effective coping strategies is an important health care function.
Introducing various forms of relaxation and stress relief A list of independent health care interventions that are helpful to
techniques provides patients with options other than substance patients with substance use disorders is found in Table 3.
Table 3. Independent Health Care Interventions and Rationale for Patients with SUDs
Independent Health Care Interventions Rationale
Establish a therapeutic relationship with the patient. This will increase the patient's trust in you and give them a
feeling of safety and security.
Treat confused patients with dignity and respect. Being treated with dignity and respect increases patients' self-
• Use patients' proper names. esteem and self-concept.
• Do not treat patients as if they were children.
Be supportive of the patient. Support from health care providers can help encourage freedom
from substance use disorder and increase the patient's low self-
esteem.
Provide the patient with safety from trauma and harm. While under the influence of a substance, the patient cannot
maintain their own safety needs.
Assess and continually monitor the patient for adverse medical Some drugs may cause death as a result of cardiac or respiratory
sequelae of intoxication or withdrawal. failure
Assess and monitor the patient's mental status. Mental status changes and fluctuates according to ingestion of
the substance and the amount ingested.
Do reality testing with the patient. Monitoring the fluctuations in the patient's level of awareness
and comprehension enables necessary changes to be made in
the care plan.
Encourage verbalization and exploration. Help the patient These measures help increase the patient's awareness of their
connect current difficulties with substance use disorder or problem areas.
dependence. Use techniques from motivational interviewing and
stages-of-change theories.
Table 3. Independent Health Care Interventions and Rationale for Patients with SUDs (continued)
Teach the patient about substance use disorder, including the Knowledge about substance use disorder will help increase the
psychological, biological, and social ramifications. patient's awareness of the potential for problems.
Assess available support and explore options. Knowledge about available support and possible options can
help patients recognize their potential strengths.
Provide role modeling. Role modeling sets an example and shows patients that they can
be drug-free.
Administer psychopharmacological medications, when Psychopharmacological medications are generally used
necessary, as directed by the prescribing clinician. for detoxification, in emergencies as antagonists, and for
maintenance therapy (e.g., methadone for heroin).
Teach and encourage the use of relaxation techniques and other Relaxation can provide relief from tension and decrease anxiety.
self-management strategies. Coping skills can be learned and practiced.
From Colibri Healthcare, LLC., © 2021.
HOLISTIC CONSIDERATIONS
Since the 1970s, scientific research has endorsed the following Although most treatment programs are based on conventional
key principles as the foundation for effective substance use therapies, various complementary and alternative treatments
disorder treatment: (a) recognizing that addiction is a complex have also been used to enhance the overall recovery of persons
but treatable disease of the brain; (b) understanding that with substance use disorders. Yoga and mindfulness-based
treatment programs should address all the patient’s needs, not therapies are often used to assist those struggling with addiction
just the substance misuse; and (c) using medications, especially to reconnect with their minds and bodies. They also serve to
in combination with counseling and behavioral therapies in the provide self-soothing, and they aid individuals in learning to
treatment of substance use disorders. In 1999, NIDA established respond to stressors through conscious decisions as opposed
a list of 13 principles for treatment of substance use disorders to reacting (Schuon, 2017). These complementary therapies
that flow from the key principles above (NIDA, 1999). have been so helpful that in recent years, there has been an
integration of the yogic philosophy with the 12-step model
of recovery through an organization called Yoga of 12-Step treatment but noted its promise as an adjunctive therapy
Recovery (Y12SR, 2017). (Margolin et al., 2002). Meta-analyses noted the large variation in
Acupuncture is another complementary therapy that has quality among published studies but recognized some positive
been used to treat substance use disorders. Recent research effects (Boyuan et al., 2014). One meta-study postulated a
findings on the efficacy of acupuncture in treating substance neurological mechanism explaining the efficacy of acupuncture
use disorders are inconclusive. One of the largest randomized on opiate addiction. Acupuncture is thought to activate opioid
controlled studies found inconclusive results for acupuncture receptors (Lin et al., 2012).
when used in treating cocaine addiction as a stand-alone
Case study 3
Olivia Kingsley is a 73-year-old female patient who has been Ethan asks Olivia if anyone has been hurting her. Olivia appears
admitted to the hospital because she has fallen in her apartment quite shocked by this line of questioning and asserts that all her
and sustained injuries that need further evaluation. She was injuries are from falls she has had while alone in her home. Ethan
admitted twice before in similar circumstances and continues to asks a few more questions and leaves feeling comfortable that
exhibit a slight limp because of a previous fall. Olivia lives alone Olivia is not being abused.
but has children in the area who check on her regularly. A home
health aide also visits twice a week to help with personal care Self-Assessment Quiz Question #4
issues. Olivia’s vision is somewhat impaired, and she does not
drive at night. She has a history of hypertension that is controlled After Ethan eliminates substance use disorder, what other
with medication. conditions should he consider?
Currently, Olivia’s main complaint is pain in her right arm and a. Olivia’s vision is becoming worse and needs evaluation.
right leg. Both are bruised badly, and there is a laceration on her b. It is probable that Olivia is hurting herself on purpose.
forearm. While completing an initial assessment, Ethan Carter, c. Olivia needs a neurological work-up as falling could be a
her health care professional, notices that Olivia has other bruised result of a neurological problem.
areas that appear older and more healed. Because a pattern of d. It is more than likely that Olivia has had a stroke.
injury over a period opens the possibility of an abusive situation,
Case study 4
After a couple of days at the hospital, Olivia is discharged,
although she is still complaining of significant pain and asks Self-Assessment Quiz Question #5
for pain medication frequently. She is sent home with a 15-
What should Jane, the home health care professional, do next?
day prescription for opioid pain medication, and home health
care is scheduled to have a health care professional check on a. Assess Olivia for additional falls or other injury that would
Olivia biweekly. When Jane Masters, the home health care require such a large amount of pain medication.
professional, first visits Olivia 3 days after discharge, she checks b. Report her to the local police for misuse of prescription
Olivia’s medications and discovers that she has used the entire drugs.
supply of pain medication since her discharge. c. Call her family to determine if anyone in the family is using
her medication.
d. Inform Olivia that she will not receive services unless she
uses her medications correctly
Case study 5
There is no evidence that Olivia has fallen again or experienced
any additional injuries. Upon questioning, Olivia admits to using Self-Assessment Quiz Question #6
pain relievers on a consistent basis unrelated to the level of
What question would be important to ask Olivia after finding
actual physical pain. When she does not have medication that is
out about her ongoing drug use?
strong enough, she drinks alcohol to relieve her pain. From what
Jane can determine, Olivia tends to fall when she is under the a. “When did your husband die?”
influence of some form of CNS depressant. It begins to make b. “Which neighbor gave you the pain medication?”
sense that Olivia has had so many accidents. Further questioning c. “How many pills do you take at one time?”
reveals that Olivia has felt very lonely and depressed since her d. “Does your family know about your drug use?”
husband died. At the time of his death, a neighbor offered her
“some kind of pain pill,” and she took it. Because it made her Self-Assessment Quiz Question #7
feel better, she continued to self-medicate with prescription
drugs. Jane also determines that Olivia has begun to feel the Which of the following would also be a priority question?
need to self-medicate to prevent symptoms of drug withdrawal, a. “When did you take the last pill in the bottle?”
although she did not recognize what she was experiencing as b. “When did you have your last pain pill?”
withdrawal symptoms. c. “Where do you get all your pain pills?”
d. “Does your family know you are taking this many pills?”
Case study 6
Olivia needs long-term treatment of some sort. She is abusing and the health care team, Olivia agrees to enter a residential
CNS depressant drugs and appears to be showing signs of treatment program. She will be there 3 weeks and after discharge
depression. Jane contacts Olivia’s primary care provider, and a will stay with her daughter until it is decided that she has
psychiatric consultation is ordered. In collaboration with the family recovered enough to live alone in her own apartment again.
Self-Assessment Quiz Question #8 Self-Assessment Quiz Question #9
The family is very embarrassed by the fact that they had no Which of the following will have the most influence on Olivia
idea that Olivia was abusing drugs. What might Jane say in being able to stay off of the pain pills she has been taking?
response to this? a. Having the family check on her twice a day once she is
a. “Oh, don’t feel bad, there’s no way you could have home.
known.” b. Scheduling a home health care professional to visit every
b. “It took a while for any of us to know; your mother is very other day.
tricky.” c. Educating her on the adverse effects of taking too much
c. “Well, it won’t happen again, now, will it?” pain medication.
d. “Your mother isn’t typical for people who use drugs. You’ll d. Helping her maintain a desire to stay away from ongoing
be getting some helpful materials as part of her program.” pain medication.

Of the following activities that Olivia might try out while at the
treatment facility, which one is the most likely to help Olivia
remain drug-free when she returns home?
a. Learning new line dances
b. Practicing childcare skills
c. Learning job interview techniques
d. Practicing meditation regularly
Conclusion
Because substance use disorder is widespread, it is likely includes a multimodal treatment approach consisting of possible
that health care professionals will encounter patients with pharmacological treatment; individual, family, and/or group
this problem. Patients with substance use disorders generally therapy; and 12-step or peer-facilitated groups. With motivation
cannot achieve a healthy lifestyle on their own. Treatment for and the development of self-management skills, patients with
substance use disorders should be encouraged, either in an substance use disorders can be successful in recovery.
outpatient program or in a brief residential program, which
Glossary of terms
Clarification of concepts and terms associated with chemical Organic hallucinosis: A physical disorder characterized by
dependency is necessary to begin to understand the illness alteration in thought processes in which the person affected
(American Psychiatric Association, 2013; NIMH, 2017; SAMHSA, hallucinates.
n.d.). Substance: A chemical in the form of a drug of misuse/abuse; a
Addiction: The psychological or physical need for a chemical medication or a toxin.
substance and the compulsive use of it, because of previous Substance use disorder: A disorder characterized by out-of-
intake behavior and despite harmful outcomes to the user. control consumption of a substance, resulting in biological,
Craving: An intense and persistent desire for a substance that social, and vocational functional impairment.
is both psychological and physical and can take on an urgent Tolerance: The need for greatly increased amounts of a
quality. Addressing psychological cravings is one of the most substance to achieve intoxication (or desired effect) or a
difficult aspects of early recovery from addiction. markedly diminished effect with continued use of the same
Delirium: A disordered mental state characterized by confusion, amount of the substance.
agitation, and hallucinations. Withdrawal: A physical and behavioral change that occurs
Delirium tremens (DTs): A disordered mental and physiological when blood or tissue concentrations of a substance decline in
state that can occur during withdrawal from alcohol. an individual who had maintained prolonged, regular use of the
Organic delusional disorder: A disorder characterized by substance.
alteration in thought processes in which the person affected has
false beliefs.
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36(2), 145-151. alcohol and drug education. Journal of Alcohol and Drug Education, 63(3), 5-10.
MedlinePlus. (2017). Alcohol withdrawal. https://medlineplus.gov/ency/article/000764.htm Shoff, E. N., Zaney, M. E., Kahl, J. H., Hime, G. W., & Boland, D. M. (2017). Qualitative
National Conference of State Legislatures. State Medical Marijuana Laws, 18 May 2021, identification of fentanyl analogs and other opioids in postmortem cases by UHPLC-Ion
www.ncsl.org/research/health/state-medical-marijuana-laws.aspx. Trap-MSn. Journal of Analytical Toxicology, 41(6), 484-492.
National Institute of Mental Health. (2017). Trends and statistics in substance use disorder. Smith, Kathleen. “Prescription Drug Abuse: Prevention and Treatment Options.” Psycom.
https://www.drugabuse.gov/related-topics/trends-statistics net - Mental Health Treatment Resource Since 1996, 14 May 2021, www.psycom.net/
National Institute on Alcohol Abuse and Alcoholism. (2017). Alcohol and your health. http:// prescription-drug-abuse.
www.niaaa.nih.gov/alcohol-health Substance use disorder and Mental Health Services Administration. (n.d.). https://www.
samhsa.gov/
Substance use disorder and Mental Health Services Administration. (2021, January 25). Volkow, N. D., Koob, G. F., & McLellan, A. T. (2016). Neurobiologic advances from the
Qualitative and quantitative assessment methods. https://www.samhsa.gov/workplace/ brain disease model of addiction. New England Journal of Medicine, 374, 363-371.
toolkit/assess-workplace/methods Volkow, N. D., & Morales, M. (2015). The brain on drugs: From reward to addiction. Cell,
Townsend, M., & Morgan, K. I. (2017). Essentials of psychiatric mental care: Concepts of 162, 712-725.
care in evidence-based practice (7th ed.). F. A. Davis. Yoga of 12 Step Recovery. (2017). The latest research on neuroscience, trauma healing and
United Nations Office on Drugs and Crime. (2016). A century of international drug control. the ancient practice of yoga. http://y12sr.com/about/research
https://www.unodc.org/documents/data-and-analysis/Studies/100_Years_of_Drug_
Control.pdf
HEALTH CARE MANAGEMENT OF PATIENTS WITH SUBSTANCE USE DISORDERS

1. The correct answer is C. 7. The correct answer is B.
Rationale: Answer c is the only response that encourages Rationale: Answer a is similar to answer b – but it specifies the
Richard to answer Kathy’s questions by explaining to him that “pills in the bottle." In fact, Olivia may have other pills, so the
the information is being collected to provide the best possible information would be incomplete when asking a. C and d are
care. questions for another time.
2. The correct answer is A. 8. The correct answer is D.
Rationale: Richard’s response is far enough in the past that Rationale: This acknowledges that there were reasons why drug
further assessment is not required. use disorder might not come to mind when thinking about
Olivia, but it also indicates that there are things the family can
learn about drug abuse that will help in the future.
Rationale: The results of this brief assessment should be
shared with the patient’s health care providers as a basis for 9. The correct answer is D.
determining the appropriate intervention. Rationale: Although all will certainly be helpful, there is no
way for someone to quit taking drugs without a firm personal
decision to stay away from them.
Rationale: There are several neurological problems that could
cause Olivia to fall, and she is in an age group when falls are 10. The correct answer is D.
often diagnosed. The other answers could be correct, but Rationale: Practicing meditation on a regular basis can help
they are less likely given Olivia’s living situation and physical an individual remain calm and less anxious than usual, thereby
condition. decreasing the need for self-medication. Although dancing
(response a) provides physical exercise, which is generally
good for keeping stress down, line dancing is often part of
Rationale: A thorough assessment is Jane’s first step.
the club scene where alcohol is prevalent. This is therefore
6. The correct answer is C. not a good plan for Olivia who is just coming from her rehab
Rationale: It is important for Jane to determine what level of program. Learning to take care of children (response b) can
medication Olivia is used to so that she can determine how be an engaging activity and provide possible future job
to proceed with treatment. The other questions may be of opportunities, but it may be too stressful for someone newly
interest but do not need to be asked right away. discharged from rehab. Clearly Olivia will need to get a job,
so some interview skills (response c) would be valuable for
her. Because dwelling on finding a job can be stress provoking
rather than stress reducing, response C is not the best answer.
Course Code: ANCCNC02PS
Managing Difficult Patients for Healthcare Professionals
5 Contact Hours
Release Date: August 24, 2021 Expiration Date: August 24, 2024
Faculty
Karen S. Ward, PhD, MSN, RN, COI, received BSN and MSN and is an internationally known speaker on stress and self-care.
degrees in psychiatric-mental health nursing from Vanderbilt Dr. Wilson was named the 2017-2018 American Holistic Nurse
University and a PhD in developmental psychology from Cornell of the Year. She is on the faculty at both Austin Peay State
University. She is a professor at the Middle Tennessee State University School of Nursing and at Walden University.
University School of Nursing, where she has taught in both the Debra Rose Wilson has disclosed that she has no significant
undergraduate and graduate programs. Dr. Ward’s work has financial or other conflicts of interest pertaining to this course.
been published in journals such as Nurse Educator, Journal of
Reviewer:
Nursing Scholarship, Journal of Emotional Abuse, and Critical
Care Nursing Clinics of North America. She has also presented Cindy Parsons, DNP, ARNP, BC, is a Psychiatric Mental Health
her work at local, regional, and international conferences. Nurse Practitioner and educator. She earned her Doctor of
Dr. Ward’s research interests include child and adolescent Nursing Practice at Rush University, Illinois and her Nurse
maltreatment, mental health, and wellness issues (stress and Practitioner preparation from Pace University, New York. Dr.
depression), leadership variables, and survivorship. Parson’s is an Associate Professor of Nursing at the University of
Karen S. Ward has disclosed that she has no significant Tampa and maintains a part-time private practice. She is board
financial or other conflicts of interest pertaining to this course. certified as Family Psychiatric Nurse Practitioner and a Child
and Adolescent Psychiatric Clinical Specialist and her areas of
Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, CHT,
received an MSN in holistic nursing from Tennessee State specialization are full spectrum psychiatric mental health care
University School of Nursing and a PhD in health psychology with a focus on family systems, community health and quality
with a focus in psychoneuroimmunology from Walden University. improvement. Dr. Parson’s currently serves as the chair of the
She has expertise in public health, psychiatric nursing, wellness, QUIN council, is the membership chair for the Florida Nurse
and disease prevention. In addition to being a researcher, Dr. Practitioner Network, and in 2009, she was inducted as a Fellow
Wilson has been editor of the International Journal of Childbirth of the American Association of Nurse Practitioners.
Education since 2011 and has more than 150 publications with Cindy Parsons has disclosed that she has no significant
expertise in holistic nursing, psychoneuroimmunology, and grief financial or other conflicts of interest pertaining to this
counseling. Dr. Wilson has a private practice as a holistic nurse course.
Course overview
Healthcare professionals will encounter difficult or hard to prepared and recognizing the signs and risk factors for these
manage patients during their career. Examples of these difficult occurrences. De-escalation skills, diagnosis, preventative
encounters include workplace violence, non-adherence to measures, training, and planning are all presented in this course
medical treatments, and manipulation of caregivers. This course to help healthcare professionals respond to difficult patients and
explores how healthcare professionals can avoid potentially ensure a healthy environment for everyone.
violent situations and work with difficult patients by being
Learning objectives
After completing this course, the learner will be able to do the Differentiate risk factors associated with nonadherence.
following: Compare healthcare professional interventions that may be
Interpret the early warning signs of workplace violence in used when caring for patients who are nonadherent.
patients who are aggressive. Distinguish ways in which manipulative behavior can be
Apply healthcare professional interventions for managing identified.
patients who are assaultive or have the potential to engage Choose effective healthcare professional interventions for
in workplace violence. patients who demonstrate manipulative behaviors.
● Read the entire course online or in print which requires a ○ An affirmation that you have completed the educational
5-hour commitment of time. activity.
the course. ● Complete the MANDATORY Course Evaluation.
● Depending on your state requirements you will be asked to ● Print your Certificate of Completion.
complete either:
CE Broker reporting
Colibri Healthcare, LLC, provider # 50-4007, reports course Carolina, or West Virginia, your successful completion results will
completion results within 1 business day to CE Broker. If you be automatically reported for you.
are licensed in Arkansas, District of Columbia, Florida, Georgia,
Kentucky, Mississippi, New Mexico, North Dakota, South
Credentialing Center’s Commission on Accreditation.
Activity director
Lisa Simani, MS, APRN, ACNP
Disclosures
course activity.
Disclaimer
Course verification
All individuals involved have disclosed that they have no No. 241, every reasonable effort has been made to ensure that
significant financial or other conflicts of interest pertaining to this the content in this course is balanced and unbiased.
course. Likewise, and in compliance with California Assembly Bill
INTRODUCTION
Hospitalization can sometimes be frightening, disorienting in healthcare. At issue is the right of the patient to choose a
and may even cause a patient to resort to behaviors that treatment course that is different from the recommendations of
include hostility, noncompliance, and manipulation. Healthcare the healthcare team. Discovering the cause of nonadherence
professionals working in a general hospital setting may not have is a necessary first step. If it can be determined, then patient
been given specific instructions in handling such situations. education or problem solving by the healthcare professional -
In acute care settings, security staff frequently manage the may assist in future adherence. Helping patients truly understand
occasional behavioral incident associated with patient aggression. the risks of not following the treatment regimen can go a long
However, psychiatric healthcare professional personnel are trained way toward achieving better adherence.
in the management of aggressive behavior and crises. Another way patients may demonstrate difficult behavior in a
Healthcare institutions must take necessary precautions to hospital setting is through manipulation. The term manipulate
protect healthcare professional personnel from workplace means to influence the behavior or emotions of others,
violence. The Occupational Safety and Health Act of 1970 often at their expense, for one’s own purposes. The stress of
requires that employers ensure each employee has a place hospitalization may cause a patient to resort to manipulation
of employment that is free from recognized hazards that are in an effort to meet needs that are absent in a hospital setting.
causing, or are likely to cause, death or serious physical harm Patients who demonstrate manipulative behaviors are typically
(Occupational Safety and Health Administration [OSHA], 2017). trying to gain power over the healthcare professional to get what
Healthcare professionals may experience difficulty with patients they need/want. This behavior can evoke a negative response
who are noncompliant or nonadherent treatment. The concept towards the patient from healthcare professionals and other
of noncompliance, or nonadherence, is a subject of debate clinicians.
FACTORS THAT MAY INCREASE THE RISK OF WORKPLACE VIOLENCE

Workplace violence ranges from offensive or threatening environment is that sickness and potential life-threatening factors
language to homicide. Incidents of violence are episodes or cause stress in patients, their family members, and personnel in
outbursts that involve hitting, choking, or assaulting another healthcare workplaces. Such stress can aggravate factors that
person; damaging property; throwing cups; smashing glassware, lead to violence, which is reportedly on the increase (American
and so forth. One of the difficulties with providing a safe Nurses Association [ANA], 2017).

EliteLearning.com/Nursing Page 66
Research demonstrates that among healthcare personnel, nurses that are overcrowded or otherwise uncomfortable. Healthcare
are the most likely victims of workplace violence (OSHA, 2017). facilities are also places where drugs and money are viewed as
According to one report (Dwyer, 2017), 21% of nurses have easily available. Patients, their visitors, and healthcare staff are
experienced some form of violence, verbal assault, physical all at risk for involvement with violence for many reasons. Staff
assault, or rape. The risk factors for violence vary with each may lack training in recognition and management of violent
healthcare facility, depending on location, size, and type of behavior. Patients may feel extreme anxiety because of their
care. It is a problem that the American Nurses Association has medical condition and react in violent ways. Distraught family
considered high priority (ANA, n.d.) and the ANA has been members and other visitors may think they are not getting the
instrumental in sponsoring appropriate legislation to address information they want or getting it quickly enough. Factors that
it. Common risk factors for workplace violence in healthcare may influence the risk for violence in healthcare settings are
settings include poor or inadequate security measures, poorly listed in Table 1.
lit public areas of the facility, and long waiting times in areas
Table 1: Factors That May Increase the Risk of Violence in Healthcare Settings
Patients and Visitors Staff Environment
Patients who are acutely agitated, Lack of training in recognition, early Poor or inadequate security measures.
violent, or volatile. intervention, and management of escalating,
hostile, and assaultive behavior or patients
who are potentially volatile.
Patients with a history of violence or Low staffing levels during times of specific Poorly lit corridors, rooms, parking lots,
certain psychotic diagnoses. increased activity, such as mealtimes, visiting and other areas.
hours, and shift changes.
Patients who are on criminal holds by Solo work, particularly in remote locations. Highly accessible worksites with little or no
police and the criminal justice system. privacy.
Patients with a history of trauma. Interventions demanding close physical Unrestricted movement of the public in
contact, such as examinations, treatments, or clinics and hospitals.
transporting patients.
Patients who abuse drugs or alcohol, are Shift work, including commuting to and from Long waits in emergency or clinic areas
under the influence of these substances, work at night. that are overcrowded and uncomfortable.
or are withdrawing from substances.
Distraught family members. Demanding workloads. Availability of drugs or money at hospitals,
clinics, and pharmacies, making them
likely targets for robbery.
Presence of gang members. The use of temporary and inexperienced Prevalence of handguns and other
staff; working alone. weapons; home visiting, with its
associated isolation.
Based on National Institute for Occupational Safety and Health. (2017). Occupational violence. Centers for Disease Control and Prevention. https://
www.cdc.gov/niosh/topics/violence/training_nurses.html
Occupational Safety and Health Administration. (2017). Workplace violence. U.S. Department of Labor. https://www.osha.gov/SLTC/workplaceviolence
Townsend, M. C., & Morgan, K. (2017). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (7th ed.). F. A. Davis.
Workplace violence is destructive and has a profoundly negative a team approach with security staff because both groups have
impact on healthcare professionals. Nurses may experience their own perspectives and skills to offer. In particular, healthcare
physical injuries, psychological trauma, anxiety, or even death. professionals who work in long-term care facilities should have
Feelings such as anger, depression, fear, self-blame, and training in the management of patients who are potentially
powerlessness might take over the healthcare professional’s life. aggressive; both the frequency of incidents and the delicate
This can affect the institution by causing loss of job satisfaction, nature of some patients’ conditions increase the likelihood
low worker morale, increased job stress, and increased staff of violent incidents. The areas of a hospital where violence is
turnover rate (Mento et al., 2020; OSHA, 2017). most likely to occur are the emergency department, psychiatric
Members of the healthcare professional staff need guidelines services, and geriatric units (ANA, 2021). Ideally, all healthcare
for dealing with workplace aggression, just as they do for a fire professionals should receive education on how to handle
or dangerous situations. These guidelines should be based on violence in their workplace.
INCIDENCE OF WORKPLACE VIOLENCE IN HEALTHCARE SETTINGS

Hospital workers are at high risk for experiencing violence in the likely to experience workplace violence than individuals in other
workplace (National Institute for Occupational Safety and Health professions. It continues to be a critical issue for all hospital
[NIOSH], 2017). Data collected between 2002 and 2013 revealed workers. Individual states have enacted legislation to help curb
the incidence of nonfatal assaults on hospital workers was 8.3 this problem. Through these efforts, emergency departments
assaults per 10,000 workers. This rate was much higher than the in particular have added secure entry systems and, as much as
rate of nonfatal assaults in private sector industries, which was possible under current budget restrictions, additional security
two per 10,000 workers. Healthcare workers are four times more personnel.
PREVENTION OF WORKPLACE VIOLENCE IN THE HEALTHCARE SETTING
Nurses in all healthcare settings should expect training in dealing prevention policies, and fostering good working relationships
with patient aggression. Being prepared for situations that may with security personnel (Martinez, 2016; Edward, et al., 2016).
escalate allows healthcare professionals and other staff to defuse Patients are not the only individuals responsible for workplace
potentially violent situations before injuries occur. Areas where violence. Family, other visitors, staff, and vendors are all potential
patients are most likely to become violent require higher staff- aggressors. Nurses educated in de-escalation techniques may
to-patient ratios to decrease incidents of violence. Suggested be able to help any of these individuals calm down rather than
prevention strategies include maintaining a means of escape create a violent episode. Everyone benefits when an emotionally
from the threat until help arrives, consistent enforcement of charged situation does not end in violence of any sort.
Evidence-based practice! Although most healthcare professionals work in places that have some sort of building that contains
staff, patients, their families, and the supplies needed to administer care, home health healthcare professionals are out in the
community. This requires some additional considerations when it comes to working safely. For one thing, home healthcare
professionals are usually on their own – there is just one of them! Although history has shown that the public has a soft heart for
healthcare professionals, it is imprudent to count on that alone. Nurses going out into the community and rural countryside must be
cognizant of the norms for the area. They need to follow the policies and procedures of their workplace. Keeping safe practices in
mind, such as making sure all car maintenance is up to date, is important. Consulting other home care workers and reading articles
about current safety issues (Marrelli & Rennell, 2020) that focus on the unique needs of in-home providers help prepare for safe and
successful visits.
DIAGNOSTIC ASSESSMENT
The following are the Diagnostic and Statistical Manual of Mental behavior. Of course, circumstances may warrant additions to the
Disorders (5th ed.; DSM-5) diagnoses and North American list of diagnoses for any specific patient, but those listed here are
Nursing Diagnosis Association (NANDA) nursing diagnoses likely for anyone experiencing potentially aggressive behavior
that might be applicable to patients with potentially aggressive and mental health issues.
DSM-5 psychiatric diagnoses
Patients considered more at risk for becoming aggressive are ● Neurocognitive disorders
those who have had a previous violent outburst: The highest ● Alcohol and other substance use disorders, intoxication, or
predictor of violence is a previous violent episode. Patients with withdrawal
the following DSM-5 ● Bipolar disorder and/or mania
mental disorders may exhibit aggression (American Psychiatric ● Schizophrenia
Association, 2013): ● Borderline personality disorder
NANDA nursing diagnoses
The NANDA nursing diagnoses that are often considered ● Memory, impaired
with patients who are at risk for violence include the following ● Nonadherence
(Herdman & Kamitsuru, 2018): ● Self-esteem (chronic low, risk for low)
● Confusion (acute, chronic) ● Self-mutilation or risk for self-mutilation
● Coping (ineffective, readiness for enhanced, defensive) ● Social interaction, impaired
● Fear ● Suicide risk
● Hopelessness
PREVENTION AND EARLY DETECTION
Nurses need to be aware of how they deal with patient anger. ● Inform the patient that violent or aggressive behavior is not
For example, becoming angry in response to anger will not acceptable.
be therapeutic and will actually create a situation in which ● Use calming statements to lower the patient’s anxiety and
the healthcare professional is unable to defuse a patient’s decrease the likelihood of aggression.
aggression. Such behavior will more likely intensify the patient’s ● Encourage the patient to talk things through rather than
emotions. Overly controlling behavior may lead to a power acting out.
struggle with the patient. Simply withdrawing from an angry ● Ask very simple, short-answer questions and not broad
patient will almost always be ineffective. If the patient’s angry questions in these situations.
feelings are escalating, the patient is communicating loss of ● Anticipate potential problems; have a plan for obtaining
control and needs help regaining composure (Townsend & help from security and/or other staff members, as well as an
Morgan, 2017). escape route out of the patient’s room.
Nurses should not overlook personal feelings of anxiety during ● Know each patient’s history and current problems. Consider
an interaction with a patient. If their intuition gives them a obtaining an order for medication to calm a patient who
message that a patient may become dangerous or that the has a history of aggressive behavior (if this appears in the
situation may be getting out of hand, healthcare professionals patient’s history or if the patient’s behavior suggests loss of
should do the following: control and emotional escalation).
● Seek help early. ● Be alert to patients whose primary or secondary diagnoses
● Use healthcare professional skills to establish and maintain a are associated with a high degree of potential for violent
trusting relationship with the patient. occurrences (e.g., patients experiencing delirium or
● Conduct a thorough psychosocial and mental status dementia, and patients with certain substance use disorders).
assessment. Nurses should request a psychiatric consultation for any patient
● Be a good monitor of a potential crisis. who demonstrates violent behavior. A thorough assessment
● Pay attention to “gut” reactions. is crucial in making a correct diagnosis so that appropriate
treatment may be initiated (Townsend & Morgan, 2017).
EARLY WARNING SIGNS
Considering the source and target of the patient’s anger, as A history of previous violence is the highest predictor of future
well as the likelihood of escalation, is important. Patients who violence. Patients who are at risk for violence often have a history
are potentially violent are often demanding, argumentative, of recent acts of aggression or violence and might exhibit the
hostile, and perhaps challenging and blatantly threatening in following behaviors (NIOSH, 2017):
all their interactions. This behavior may be directed toward staff ● Becoming extremely loud, shouting, and making menacing
members, other patients, or the patients’ family and friends, verbal or physical threats.
depending on the situation. Authority figures are often the ● Becoming physically tense and appearing rigid and tight.
recipients of verbal and other abuse, although anyone who is ● Clenching their teeth and hands or wringing their hands.
“in the way” may be the target of patients who cannot control ● Becoming quite agitated, anxious, and restless; pacing
themselves. around if mobile; seeming quite jittery.
● Exhibiting a labile mood but mostly anger.

PRELIMINARY ACTIONS
The healthcare professional staff should carefully manage ● Decrease the stimuli for the patient. The loud and unfamiliar
patients who are agitated and seem to be at risk for violence. noises of the hospital may be particularly stressful, and bright
The following steps are important for healthcare professionals to lights may be bothersome.
remember in these situations (NIOSH, 2017; OSHA, 2017): ● Avoid any behavior that may be interpreted as aggressive
● Maintain a demeanor that helps defuse anger. Present a (e.g., moving rapidly, getting too close, touching, or
calm, caring attitude. speaking loudly). Physical touch can be a trigger. Patients
● Give patients who exhibit irritability choices and options, but may misinterpret the contact and feel threatened with bodily
make sure they are valid, true choices and options. harm, and they may feel the need to defend themselves.
● Do not be demanding and argumentative; perhaps some Delay procedures that may escalate a patient’s potentially
rules or procedures can be waived temporarily. Patients who violent behavior.
are angry and potentially violent generally feel helpless and ● Before the situation gets out of control, check the
powerless. They need help with their self-control. environment. Look for potentially dangerous objects and
● To avoid power struggles with these patients, do not confront remove them if possible. Items such as glasses, scissors, food
them. This approach will help de-escalate the patients’ utensils, and other breakable or sharp objects can be used as
behavior and the situation. weapons.
● Open and consistent communication should be ongoing ● Avoid being alone and vulnerable with a patient who is
among staff members and between the patient and the staff. potentially violent or being trapped in a room away from
Talk to the patient. Try to find out what is precipitating this the exit; stay between the patient and the door. Team up
crisis. with another member of the staff when encountering such a
● Do not match the threats. Do not give orders. Acknowledge patient; there can be safety in numbers.
the person’s feelings (e.g., “I know you are frustrated.”). Ask ● Alert other members of the healthcare professional staff of
the patient what they would like done (e.g., “How can the a potential problem. Do not call on new and inexperienced
staff help?” “How can I help?”). staff members. Additional personnel should be available to
help with a crisis.
WHEN VIOLENCE ERUPTS
If the risk for violence escalates and a patient is behaving in a is desirable. Knowledge of the hospital’s policies, state laws
threatening manner, the healthcare professional staff must act and regulations, the patient, and appropriate and available
quickly. This may mean administering medication against the interventions is necessary for successful resolution of a violent
patient’s will. In such situations, following the textbook protocols episode.
may not be possible. The best rule of thumb is to follow
hospital policy and state laws, protect the patient, and provide Healthcare Professional Consideration: All healthcare
for the safety of all present. Careful and timely evaluation of professionals are taught how to give an intramuscular injection
the situation means containing any violence using the least – carefully measuring the amount, “mapping” out the site,
restrictive means possible. Rigid adherence to precise procedure wiping the area clean, inserting the needle, aspirating, and
may not result in the desired outcome. then proceeding to inject the liquid. Admittedly, some of these
Nurses should always seek assistance in an emergency. They steps have been brought into question, but when dealing with a
should get help from the security staff, other available healthcare patient who is agitated or possibly combative, the focus needs
professionals, or any other hospital personnel. A patient who to be on the outcome, which is that the patient safely receives
has a weapon should be disarmed by persons who are trained the calming agent. How does this translate to an actual patient
to do so. If the patient cannot be disarmed easily, the safety setting? As a patient is crawling down the hallway, trying to
of healthcare personnel and that of others in the area must be get away from the four healthcare professional assistants who
considered. Shields and barriers may protect against knives but are holding him down, the healthcare professional needs to
not against a patient with a loaded gun. Other patients and intervene quickly. In this situation, the healthcare professional
visitors should be moved to safe and secure areas, and local should try to calm the patient and create a safe environment
police should be engaged in such a situation. as soon as possible. The use of restraints is desirable before
medication to control difficult behavior is administered. On
If the patient is unarmed, antianxiety or antipsychotic some occasions, restraint provided by staff may be all that is
medication, physical restraints, or possibly both may be needed. initially available. Once the staff has the patient’s movements
This is often the decision that needs to be made by appropriate under control, the healthcare professional must act swiftly and
medical staff, quickly and with assurance, based on existing decisively in administering the medication, even if this means
protocols and appropriate training. Erring on the side of caution giving a non-textbook injection. Those holding the patient can
is the best choice because the safety of all in the area is a only do so for a certain period. Any such interventions should
priority. At the same time, the lowest level of effective restraint be in keeping with state laws and institution policy.
RESTRAINTS
Each healthcare institution has, or should have, some guidelines situations, and all healthcare professionals should be aware of
for the use of chemical or physical restraints in potentially violent the procedures used in their institution.
Chemical restraints
The medication protocol generally consists of giving a patient The healthcare professional responsibilities involved in handling
who cannot be “talked down” an initial, low dose of a high- a violent episode by medicating a patient with a potent
potency antipsychotic (such as haloperidol) or a short-acting pharmacologic agent include the following:
antianxiety medication (such as a benzodiazepine). Oral ● Checking for or obtaining a healthcare practitioner’s order to
medications may be offered first, but if escalation is rapid, administer medication.
an intramuscular medication may be required. The patient is ● Preparing the medication: capsules, tablets, or liquid;
observed at 15-min intervals or possibly on a continuous basis. In intramuscular injection, intravenous drip, or butterfly infusion.
some instances, medication may be given as often as every half ● Assessing the patient’s vital signs before giving the drugs if
hour until the violent episode is in check or the maximum dose is this can be done safely.
reached. ● Informing the patient of the procedure that will follow and
providing reassurance and support if needed.
● After the medication has been administered, observing the ● Periodically checking the patient’s vital signs.
patient, assessing for a decrease in signs and symptoms ● Documenting the incident and the medications given by
of aggression, and noting any untoward side effects of recording the information in the patient’s medical record or
medication given. as the institution directs.
Mechanical restraints
As with protocols for using medications, each healthcare The healthcare professional responsibilities involved in handling
institution should have a procedure to follow for mechanically a violent episode by mechanically restraining a patient include
restraining a patient. Without an order for an involuntary the following:
commitment, however, the patient cannot be held against their ● Staff should monitor the patient frequently, according to the
will (Tamura et al., 2015). facility’s protocol.
When a patient in a general hospital setting is at high risk for ● At least every 2 hr, the restraints should be untied and the
harm, the number of staff members needed to restrain the patient’s position should be changed (Francis & Young,
patient depends on the patient’s size, strength, and potential for 2017). Although the patient may not need to be restrained
violence (Francis & Young, 2017). The general recommendation this long.
is that one staff member needs to be available to hold each ● Staff should not negotiate with the patient.
extremity, and an additional staff member must be available ● Staff should not confuse the patient with options.
to apply the restraints; if six staff members are available, one ● Staff should remember that this patient is out of control.
person can support the patient’s head. ● Staff can say something like the following: “We feel you are
not in good control of yourself right now. We will help you
The patient is held by the arms and legs and walked, carried, calm down.”
or placed in as comfortable a position as possible (usually in
a hospital bed with side rails up) and put in wrist and ankle The room should be checked for potentially dangerous objects.
restraints. These restraints may be cotton, gauze, cloth, or Nurses should remove any watches, eyeglasses, jewelry, shoes,
leather, depending on the patient’s size and strength. belts, and other items that could be a hazard. No place is
absolutely free of danger. Patients have broken light bulbs and
Ideally, one person (one of the registered healthcare cut themselves with the shards or used pajama waist cords to
professionals) should be in charge of a group of five or hang themselves. Nurses should be cautious and aware. Nurses
six staff members. If no one is in charge, the possibility should look around the area from the patient’s eye level so they
of miscommunication can produce a disjointed effort. can see what the patient sees.
Consequently, the patient may escape and be harmed or do
harm. The confusion that ensues when no one is in charge The safety of the patient and the staff should be considered at all
invariably adds to the patient’s sense of being out of control times. The goal is to demonstrate no tolerance for the violence
and thus escalates the situation. The decision as to which staff and to present the intervention as not punitive but an attempt to
member will be in charge should be made before any action help the patient regain some self-control over violent behavior.
is taken. A “show of force” of five or six staff members may be Patients should be shown respect and allowed to maintain their
enough to defuse the situation. dignity. The staff should know the patient’s name and use it.
The best approach toward the patient is a uniform one. All staff Nurses should use calming statements or phrases and always
members should move or walk toward the patient together. explain step-by-step to the patient what is happening. They
Sometimes, this simple show of force subdues a patient. Before should be firm and provide information on why the staff is
the approach is undertaken, to avoid confusion, the team leader acting the way they are. For example, if giving an injection,
should assign which staff member will hold which extremity. the healthcare professional should say tell the patient that the
Staff members should try to be calm themselves. They should injection is intended to relax and calm the patient. While putting
not speak loudly; instead they should be firm and speak slowly, on restraints, the healthcare professional should acknowledge
clearly, and precisely. A soft voice may have a quieting effect on that they may not be comfortable but that they will be removed
the patient. as soon as possible. Providing these brief explanations will take
away the unknown and, ideally, help the patient accept the
interventions a little more calmly.
HEALTHCARE PROFESSIONAL INTERVENTIONS FOR PATIENTS WITH
POTENTIALLY AGGRESSIVE BEHAVIORS
The role of the healthcare professional in the management of a opening for the patient to vent verbally rather than resorting to
patient’s aggressive behaviors will be found within the protocol, violence. Becoming aware of the potential of a violent episode
policy, or procedure manual of each institution, as well as in before the situation escalates is a skill healthcare professionals
the scope of practice or mental health act of the state. Nurses should master. When a situation has arisen that requires
need to remain nonconfrontational. A calm, quiet approach intervention, healthcare professionals must carefully document
that acknowledges the patient’s anxiety and probable dislike of all that happened, including any precipitating factors, attempted
the situation will provide the best possibility of de-escalating interventions, and the length of time it took to resolve the
the patient’s aggression. By acknowledging the patient’s situation. Within this framework, the healthcare professional
feelings and providing the patient with an opportunity to talk, interventions in Table 2 may apply.
the healthcare professional establishes rapport and offers an

Table 2. Independent Healthcare professional Interventions and Their Rationale for Patients Who Exhibit Aggressive
Behaviors
Independent Healthcare professional Interventions Rationale
Use good interpersonal skills. Be nonconfrontational. Establishing rapport can help decrease the likelihood of
aggression.
Assess for potentially violent occurrences. Maintaining alertness to possibilities of violence allows the
healthcare professional to be prepared.
Acknowledge the patient’s feelings (e.g., “You seem angry.”). Providing an opening for verbal discussion can decrease possible
Listen actively. violent episodes.
Anticipate a potential problem. It is important to stay aware of environmental cues for escalating
violence.
If a patient’s anger is escalating, communicate verbally with then Attempt to foster a therapeutic relationship by conveying
in a soft but firm voice. empathy, acknowledging the patient’s feelings.
Encourage patients to express anger verbally rather than by Dealing with anger in this way will create a safe environment and
“acting out” their feelings. help the patient learn more effective coping skills.
Be respectful of a patient’s personal space. Allowing a patient plenty of room sometimes keeps anger at a
lower level.
Teach stress reduction techniques (e.g., deep breathing). Providing alternative outlets for anger is good patient education.
Continuously observe patients who are potentially dangerous to Evaluation is part of the healthcare professional process.
themselves or to others.
Assess the patient’s coping skills and ability. Crisis intervention techniques may work to prevent violent
eruption.
Help the patient maintain control by offering choices, talking, or Physical activity can sometimes defuse angry outbursts.
walking.
Initiate or collaborate on a plan that includes a team approach to Prepare ahead of time for potential violence.
restraining a patient.
Alert others of the potential problem. Do Use of a team to demonstrate a show of force is often all that is
not approach an aggressive patient alone. needed to defuse a potentially violent situation.
Monitor the situation for the safety of others and the staff. Ask those who can to leave the area if violence is erupting.
Based on Halter, M. J. (2018). Varcarolis’ foundations of psychiatric mental health nursing: A clinical approach (8th ed.). Elsevier.
Townsend, M. C., & Morgan, K. (2017). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice 7th ed.). F. A.
Davis.
Healthcare is one of the professions where the incidence of of changes in the environment involves paying attention,
workplace violence is particularly concerning to governing intentionally. As both witnesses to and recipients of workplace
agencies such as the ANA (2017), OSHA (2017), and, within the violence, healthcare professionals can campaign this cause
Centers for Disease Control and Prevention, NIOSH (2017). at their facility to increase the care and safety of all staff. The
Nurses need to educate themselves on how to identify healthcare profession does not tolerate violence of any kind,
institutional policies that might put them at higher risk for from any source (ANA, 2021).
workplace violence. They should learn how to recognize The best way to deal with any patient’s violent behaviors is to
warning signs and behaviors and how to develop a workplace defuse the agitation during the early stages of escalation. Nurses
violence-prevention program. The Centers for Disease Control need to watch for early warning signs and try to avoid dangerous
and Prevention offers a free online course, Workplace Violence outbursts. When this fails, their own safety and that of other
Prevention for Nurses (https://www.cdc.gov/niosh/topics/ patients and staff members, as well as that of the patient, must
violence/training_nurses.html). Developing an awareness be considered.
Case study 1
Martha, who is a newly graduated nurse, is working on a detox
unit. Susan is her lead nurse. Susan has asked Martha to go Self-Assessment Quiz Question #1
quickly and administer an injection to a newly committed patient What should Susan do immediately?
who is trying to get out of the hospital. Martha has drawn up a. Quietly tell Martha to “go ahead and give him the
the medication and goes to where she finds the patient on
injection.”
the floor, physically restrained by four coworkers. The patient
is constantly trying to get away by moving along the floor in a b. Announce loudly to all, “Carefully lift him up and carry him
crawling manner, keeping his hips in motion. The staff is getting to his room.”
tired. Several minutes go by while Martha is attempting to c. Ask Martha, “Why can’t you just give this medication as
give the injection. Susan comes to the group and realizes the you were asked?”
difficulty Martha is having. d. Take the syringe from Martha, and give the injection
herself.
What action should Susan take later?
a. Tell Martha that she is not working out on this unit and will
need to transfer to another one.
b. Ask Martha to submit her resignation as she does not seem
to be doing a good job.
c. Take some time with Martha to explore her feelings about
the situation and why she failed to give the injection.
d. Meet with the staff, who were holding the patient down,
and explain to them that Martha is just inexperienced.
Case study 2
Erik Nilsson is admitted to a large general hospital for a surgical
procedure scheduled for early the next morning. He is 68 Self-Assessment Quiz Question #3
years old, and English is his second language. Although he can What would Jackie’s best response be to this information?
understand some words and phrases, his ability to speak in a. Make a note to ask Erik about his “mood swings.”
English is extremely limited. Erik is accompanied to the hospital
b. Ask Astrid to describe what she means by “mood swings.”
by his daughter, Astrid, who can translate for Erik during the
admission process. She tells Jackie, the healthcare professional c. Tell Erik that Astrid said he had “mood swings.”
conducting the interview, that her father lives with her and d. Inform the doctor that Astrid reported Erik having “mood
her family. Astrid says that she does not think he is especially swings.”
worried about his surgery but did add that lately she has noticed
that her father exhibits mood swings.
Case study 3
That evening, Erik speaks in an agitated manner, in Swedish,
to another patient. Jackie, his evening healthcare professional, Self-Assessment Quiz Question #4
goes to Erik’s bedside to calm him down and see what is Based on the information presented, what healthcare
wrong. He is gesturing and muttering to himself, quite loudly at professional actions should Jackie take at this point?
times. Jackie notifies the physician on call. When the physician a. Arrange for security to send someone to stay right outside
examines Erik, he still appears agitated but somewhat calmer.
Erik’s room.
The attending practitioner orders a sedative and informs
Jackie that he will check with her again in an hour. Erik falls b. Locate some restraints and place them in Erik’s room.
asleep in a short while. The rest of the evening shift progresses c. Check on Erik at frequent intervals throughout the night.
unremarkably. d. Treat the patient the same as any other patient.
Case study 4
Jackie wakes Erik at about 6:00 a.m. and administers his manager: “I’m not sure what’s going on with Erik, but I feel
preoperative medications. Erik is taken to surgery at 7:00 somewhat frightened of him.”
a.m. The surgery goes well, with no complications. Erik has an
uneventful recovery and is returned to his unit at 2:00 p.m. His Self-Assessment Quiz Question #5
daughter and son-in-law are waiting to see him.
What is the best action for the nurse manager to take at this time?
Although he appears somewhat sleepy, Erik is mumbling to a. Instruct Jackie to pass information on to the next shift
himself and gesturing with his hands. Neither his daughter nor
regarding Erik’s behavior.
his son-in-law can understand what he is saying. They try to visit
with him briefly but finally leave, telling him to get some rest b. Remind Jackie that she is expected to act independently,
and they will return later. not rely on her supervisor.
c. Go with Jackie to visit Erik and see if together they can
Erik dozes off, but when he awakes, the unusual behaviors figure out what is going on.
seem to increase. Erik’s voice becomes louder. He then begins d. Make sure that Jackie did nothing to anger Erik while
to appear very tense, grimacing and clenching his fists. When caring for him.
Jackie approaches him, he seems angry with her, and she is
confused as to why. The nurse reports her concerns to her unit
Case study 5
Jackie and the nurse manager decide that they both will go to
Erik’s room together to conduct a postoperative assessment. Self-Assessment Quiz Question #7
As they approach Erik’s bedside, he begins shouting, trying to Which of the following would be the best response to Erik
pull out his intravenous line and catheter, and attempting to following his behavior?
leap out of the bed. He picks up a water bottle that was on his
over-the-bed tray and throws it at the healthcare professional unit a. “You know this kind of behavior cannot be tolerated here.”
manager. It hits her on the arm, stunning her but not hurting her. b. “No one here is deserving of your violent actions.”
c. “You seem to have lost control. We are going to help you
Self-Assessment Quiz Question #6 calm down.”
d. “Now why would you do something like that?”
Of the following, which is the best choice for the nurse
manager to do first?
a. Initiate a call for help from the rest of the staff.
b. Ask for an interpreter to be sent to the unit.
c. Have someone call Erik’s surgeon.
d. Call Erik’s family.

Case study 6
Staff arrive on the scene ready to assist in restraining Erik. In
the meantime, a Swedish-language interpreter has come to Self-Assessment Quiz Question #8
the unit. After the interpreter is introduced, Erik seems to calm The nurse manager asks the interpreter to convey to Erik which
down considerably. of the following?
a. “You seem to be upset. Tell us what’s bothering you.”
b. “Why are you behaving so poorly?”
c. “What are you thinking? Throwing things is not allowed
here.”
d. “Were you really trying to hurt someone?”
Case study 7
The on-call healthcare practitioner responsible for Erik’s care use Swedish-speaking personnel when available, and maintain
arrives and, after reviewing the situation, orders medication close observation of the patient. Jackie asks the team why Erik
to calm Erik. The interpreter tells Erik, in his own language, behaved in this way.
about the medication and why he is receiving it. Erik responds
favorably to this and accepts the medication. A staff member Self-Assessment Quiz Question #9
is assigned to remain at Erik’s bedside until he falls asleep. Soft
restraints are made available at the bedside in case they are What response is most likely accurate and helpful to Jackie?
needed. a. “We really can’t say.”
b. “It’s hard to know. What do you think?”
After this incident is under control, the unit manager, Jackie,
and the other staff involved go to a conference room to review c. “Some people are just that way.”
the episode. A plan is made to confer with the family about d. “It is not possible to say accurately why Erik is behaving in
Erik’s reported “mood swings,” request a psychiatric evaluation, this manner.”
Case study 8
The nurse manager may also tell Jackie, “Often patients will
react aggressively, and the staff has no sure way of knowing why Self-Assessment Quiz Question #10
this happens. It could be that the ‘mood swings’ mentioned by What guided everyone on the staff and facilitated the positive
the daughter are connected to Erik’s current behavior. It might outcome?
be the unknowns of the hospital process or of what the findings a. No one person tried to tell others what to do.
from his surgery will indicate. The fact that Erik does not speak
b. Everyone on staff liked and felt sorry for Erik.
English well may increase what might be normal anxiety to a
frightening level.” c. Jackie had had a lot of experience dealing with aggressive
patients.
d. The staff all kept in mind that the most important thing is
to provide a safe environment.
NONCOMPLIANCE
There is some debate among healthcare professionals regarding
the concept of noncompliance. Healthcare professionals have Healthcare Professional Consideration: Sometimes,
argued that a diagnosis of noncompliance labels the patient patients who need to take medication regularly are the
negatively, arguing that it places the emphasis on the patient’s ones who are the most worried about addiction. In some
behavior instead of on a mutual process with the healthcare cases, the family is also worried that their loved one will
professional and other healthcare providers. At the heart of this become addicted. In many cases, prescribed drugs are
argument is the issue of the right of the patient to choose a reducing symptoms, not curing the disease. Many psychiatric
treatment course that is different from the recommendations of medications reduce symptoms, but, from the patient’s
the healthcare team. perspective, the side effects seem to be worse than the
symptoms. When patients begin to feel better, they stop
Treatment adherence is usually associated with optimal health. taking their medication. After a period of time without the
The most obvious result of nonadherence is that the disorder medication, the symptoms return, and the patients must
may not be relieved or cured. For example, when patients with start the cycle all over again. Education of patients and their
glaucoma fail to take their prescribed medications, optic nerve families is critical in helping them understand why they are
damage and blindness may be the result. For patients with an taking their medications, the expected side effects, when
erratic heart rhythm, failure to comply with suggested treatment there is reason to be concerned about developing tolerance
can lead to cardiac arrest. Stroke may be the outcome when or dependence, and that continuing the medication is
people with high blood pressure ignore prescribed treatment. what will make them continue to feel better. A similar
Failing to take prescribed doses of an antibiotic can cause an situation exists in the frequent nonadherence with antibiotic
infection to flare up and may contribute to the emergence treatments. Although patients are told to take the entire
of drug-resistant bacteria. These failures to follow healthcare prescription, they often stop once they feel better. Again,
suggestions are not only frustrating but are also costly because education is the key to patients’ adherence to treatment.
of the undesired patient outcomes. Verbal instruction followed by giving the patient a written
pamphlet is often necessary to achieve adherence.
INCIDENCE
Although it is almost impossible to correctly determine statistics average cost of nonadherence per person was up to $44,000 a
related to nonadherence, estimates have been made. It is year.
estimated that 125,000 deaths and up to 10% of hospitalizations Medication nonadherence leads to poor health outcomes,
could be prevented, as well as between $100 and $289 billion increased health costs, and increased health risks for individuals
saved, if patients took their medications as prescribed (Boylan, and populations. Misuse and overuse of antibiotics have
2017; Cutler et al., 2018). That represents between 3% and 10% contributed to the emergence of antibiotic-resistant strains of
of total U.S. healthcare costs. bacteria (U.S. Food and Drug Administration, 2020). Population
One meta-analysis (Cutler et al., 2018) examined the economic health is affected by medication nonadherence; an example
impact of numerous different disease processes and found the of this is persons with tuberculosis who did not adhere to
treatment protocols, creating the antibiotic-resistant tuberculosis Patients with mental health disorders are frequently nonadherent
strain now evident (Centers for Disease Control and Prevention, with medications. Some psychiatric medications do have
2017). intrusive side effects that may seem to the patient more difficult
Patients fail to take medications as prescribed approximately to bear than the illness itself. Patients who are nonadherent with
50% of the time, which often leads to hospitalization and medications may also be nonadherent with interventions such as
emergency room visits (Brown & Sinsky, 2017). One of the rehabilitation, relaxation, counseling therapy, quitting smoking,
recommended means of improving adherence is to involve or losing weight.
the patient in the development of the treatment plan (Brown &
Sinsky, 2017).
HEALTH BELIEF MODEL
Many attempts have been made to create a conceptual model through skill practice and positive reinforcement so that the
of adherence that will enable healthcare providers to predict patients come to see that they are capable of change.
and understand patients’ behavior. The Health Belief Model The model postulates that people choose healthcare actions
offers some understanding of the phenomenon of adherence. when they are faced with a threat to their health. The actions
The model proposes reasons for people’s varied and unique they choose depend on their perceptions of the situation. They
responses to illness (Jones et al., 2015). The significance of decide how much of their personal goals they might be risking
this model is that it suggests that patients’ choices depend on and compare it with how severe the threat is to their health.
their beliefs, not necessarily on the medical evaluation of the Then a further determination is made as to whether the costs to
situation. their lifestyle are worth the potential benefits. Unfortunately, a
The Health Belief Model proposes that changes in beliefs about lot of this “balance sheet” is based on personal viewpoints and
the severity of and susceptibility to a health outcome and its not on medical facts. Even when patients decide on a course
consequences are associated with the motivation to take action. of action that is adherent, they struggle with long-term habits
Once an individual feels threatened, a decision is made from that must be overcome. Lifelong habits are difficult to change,
among alternative actions based on a cost-benefit analysis. This and the ease of continuing a previous pattern of behavior works
model also emphasizes the concept of self-efficacy. Patients against making healthy lifestyle changes (Jones et al., 2015). For
must feel capable of mastering their environment and behavior many patients, nonadherence may be the perception that the
to risk trying to make behavioral changes. If they do not feel illness is less of a problem than the treatment. Some changes are
capable, assistance may be offered by healthcare providers much more difficult than others as well.
LEGAL AND ETHICAL ISSUES
Healthcare professionals face increasingly complex situations professionals must be aware of legal guidelines. This area
in which the patient’s wishes may deviate from the treatment of healthcare is changing quickly. Healthcare professionals
recommendations. Some ethical guidelines can help need to be clear about their obligations to patients and be
healthcare professionals choose a response to a patient who is knowledgeable about patients’ rights.
nonadherent. In addition, to practice within the law, healthcare
Rights of the patient
Inviolability is the fundamental right of every individual to be left becomes unclear when the perspective is one of social
alone. The US Constitution and Bill of Rights are based on this responsibility. Some ethicists believe that people can have both
principle. The individual has authority over what happens to their individual autonomy and responsibilities to one another.
body. In practice, however, the situation is not always so clear. The issue of mandatory testing for communicable diseases
In some instances, individual rights may interfere with the rights illustrates the dilemma of conflicting principles. Inviolability
of others. In addition, fluctuations in public sentiment may affect would guarantee the individual the right to refuse such testing.
the decisions made by practitioners and institutions. The principle of social responsibility would support mandatory
Ethicists differ in their perceptions about the dilemmas that testing because the individual has the obligation to participate
healthcare professionals face. The concept of personal freedom to protect others.
Legal concerns
One legal issue that affects Healthcare Professional when other than the patient. Unless otherwise indicated, patients
discussing patient adherence to treatment is the issue of are assumed to be making competent choices about their
competence. A patient is considered competent if they are able healthcare.
to participate in making decisions, which means the patient has At times, however, patients may be caught in a frustrating
the ability to comprehend information, understand choices, contradiction between the issues of adherence and competence.
and communicate their decision verbally or nonverbally to A patient may refuse a treatment recommendation. Healthcare
the healthcare team. For example, patients must be able to professionals may label the patient incompetent because of
understand the nature of their illness and the available treatment the refusal. In this situation, a cognitively capable patient has
alternatives. Equally important is an understanding of the made an informed decision. However, because the patient has
consequences of any decision the patient might make about made the decision, which opposes that of the treatment team,
these alternatives. healthcare professionals view the patient as incompetent.
Patients are presumed to be competent. This assumption means
that the burden of proving incompetence belongs to parties
Special cases
Rights of Women Who Are Pregnant unborn fetus versus the rights of the mother evokes intense
Pregnancy offers a unique slant to the issue of patients’ rights. emotions on both sides of the issue.
For some people, the fact that the fetus is affected by the Withholding Nutrition
mother’s behavior alters the mother’s right to personal freedom. There is little consensus on the ethics of withholding or
The legal system has increasingly overridden the right of the withdrawing nutrition from patients. When a patient chooses
pregnant mother to disregard medical advice. The legal basis for to refuse nutrition, it is often difficult for healthcare providers
these decisions is weak. However, societal support for protecting to honor this wish. Healthcare professionals may be concerned
the unborn fetus can result in a disregard for the rights of the about participating in behavior that will lead to hunger or thirst
pregnant woman. The ongoing debate over the rights of the in the patient. The American Nurses Association (2015) maintains

the position that the decision to withhold artificial nutrition and beliefs, they should be fully aware that by doing so their job
and hydration should be made by the patient or the patient’s might be in jeopardy in some situations.
surrogate after consultation with the healthcare team. The Patient Who Signs Out Against Medical Advice
In some ethical deliberations, a distinction is made between Leaving the hospital against medical advice (aka AMA) may be
allowing a patient to die and killing a patient. The difference an extreme example of nonadherence. It is rarely a spontaneous
lies with the intent of the actions. Nutrition may be withheld on act. There are often warning signals or repeated conflictual
the premise that, if given, it will prolong life and thus prolong interactions with staff members before the patient actually signs
suffering. This is different from starving a patient with the out of the hospital.
intent to kill them. Others argue that the finality of the act of Healthcare professionals and physicians react strongly when a
withholding nutrition makes the act untenable. patient leaves against medical advice. Healthcare providers may
It is imperative that every healthcare professional be familiar with attempt to cajole or coerce the patient into staying, since there
the legalities surrounding the patients’ right to refuse treatment. are often concerns about the patient’s safety and the providers’
They should find out if there are advance directives that have obligations to the patient. Healthcare professionals may also
addressed this issue. In addition, careful thought concerning feel a personal failure when a patient’s choice is to leave against
the healthcare professional’s ethical position on these issues is medical advice.
necessary. The answers are not always clear in the increasingly Patients should be free to leave against medical advice as
complex environment of healthcare today. Although it may be long as they are competent and not endangering their lives. It
difficult for healthcare professionals to act on patients’ wishes is not appropriate to medicate a patient who is nonpsychotic
that are contrary to their own beliefs, they are usually mandated and threatening to leave against medical advice. Using drugs
to do so by the policies of the institution where they work. as chemical restraints in this manner is battery from a legal
Although they may be free to operate on their own principles standpoint.
RISK FACTORS
Nonadherence has meaning in the patient’s life. The healthcare water, then maintaining cleanliness will be more problematic for
professional must be able to carefully assess the patient’s them than it will be for someone living with modern plumbing.
situation to understand this meaning. In this way, the healthcare Knowledge of risk factors can help healthcare professionals be
professional can uncover and deal with obstacles to adherence. more aware of the possibility that patients may have difficulties
Patients’ individual characteristics and living conditions following their treatment plans. This knowledge is most helpful
will influence the likelihood of their being compliant or when it is used to prevent possible problems with compliance.
noncompliant. For example, if the patient’s home has no running
Psychological and cognitive risk factors
The most important psychological risk factors include the Sometimes giving patients time to adjust to their new status is
following: sufficient and they will be ready to accept and, ideally, adhere to
● Cognitive abilities their new treatment needs.
● Mental status Anxiety reduces the ability to process information or to make
● Denial and anxiety decisions. An anxious patient might exhibit a number of
● Addictions different emotions and behaviors, including anger, complaining,
● Depression demanding, withdrawing, or even crying. When a patient’s
● Past experiences anxiety is reduced, it will help the patient in adhering to the
Psychological and cognitive factors influence adherence to treatment regimen. Many patients are fearful of the unknown.
treatment. To be able to comply, patients must understand the Education often allays these fears.
information presented to them. Teaching should be brief and Dependence on medications and illegal substances affects
focused. Complex information should be broken into smaller adherence because these drugs may be the priority in the
and more understandable parts whenever possible. It is helpful individual’s life. If the treatment regimen interferes in any way
to simplify teaching material as much as possible. Use of written with the behaviors surrounding the need to maintain the drug
materials that reflect a fourth- or fifth-grade reading level is to avoid withdrawal, the patient will not be adherent until the
appropriate so that the patient’s level of health literacy is not substance use disorder is treated. The classic example of this
overestimated. is the patient with an alcohol use disorder who has cirrhosis.
Patients with cognitive deficits may not be able to learn. The recommended treatment is abstinence from alcohol, but
Patients must have an adequate attention span to be capable of few patients who misuse alcohol can accomplish this without
concentrating and learning new behaviors. If the patient has little professional intervention.
focus or scope of attention, the healthcare professional should A person who suffers from a depressive disorder will not take
attempt to consult with a family member or other support person in information or make decisions as well as one who is not
and determine who should receive healthcare information depressed. Individuals who are depressed are more likely than
because the patient is not capable of understanding it. others to be nonadherent to treatment plans. They commonly
Similarly, patients with changes in mental status may be unable have low self-esteem and feelings of hopelessness that can
to integrate new learning material effectively. Their judgment interfere with their ability to follow a regimen to better their
may be significantly impaired. A thorough mental status health. To a large degree, they lack the energy to comply.
examination is needed if there is any indication that a patient’s Although depression is the most common mental health
mental status is compromised. problem in the United States and one of the easiest to treat, it
Some patients may be in denial, a defense mechanism used is the least treated; thus, patients who are depressed are often
to guard against uncomfortable feelings. They may be too overlooked. Patients with depression often have other physical
frightened by their illness to be able to accept it. This can cause inflammatory illnesses such as heart disease, diabetes, or chronic
them to feel their treatment recommendations are unnecessary. obstructive pulmonary disease.
They need time to adjust and an opportunity to discuss these Finally, patients enter the healthcare system with ideas and
difficult feelings. beliefs that affect the course of their current hospitalization.
Denial is a normal part of grieving and sometimes occurs in Previous experiences that were negative can affect a patient’s
people when they find out they have a terminal illness. Illness expectations. If a patient enters the system expecting the worst,
and hospitalization involve losses for people regardless of the chances are good that healthcare recommendations will not be
prognosis, and denial may be part of any patient’s presentation. viewed in a positive light. Healthcare professionals can influence
these patients to take a more positive outlook by building trust healthcare professionals cannot meet these expectations, it can
and meeting their expectations as much as possible. When be helpful for them to explain why.
Age
The estimated rate of nonadherence for older adult patients is simple tasks such as picking up a pill become difficult. Plans for
50%. They are more at risk for nonadherence than other adult self-management must take this loss of dexterity into account.
patients. Because of their unique needs, older adult patients Older adults often find that their social support systems are
present a challenge in adherence. Their hearing, vision, and shrinking. Friends and relatives may be ill, dying, or making
cognitive functioning are likely to be impaired in some way. changes in living arrangements. This resulting isolation can affect
These impairments, as well as years of ingrained habits, make adherence.
changes in behavior more difficult.
The number of medications prescribed for older adult patients
Most patients 60 years of age or older require vision correction can be a problem. At least one fourth of older adult patients
of some sort. These impairments make self-administration of recently discharged from hospitals have six or more prescriptions
medications particularly difficult. Almost one third of all people that require self-administration. Medication costs must be
aged 65 to 79 years have significant hearing impairment. In considered, as well as the ability to obtain the medications if
older adult patients, recall is best when material is given verbally. transportation and mobility are issues (Townsend & Morgan,
Information must be delivered slowly and audibly. Reinforcing 2017).
verbal instruction with written materials is essential and teach
back will assess understanding. Print materials with large-type It is easy to see why the nonadherence rates for older adult
fonts and pictures are most effective. patients are high. This population is also less likely to be
assertive about their needs with healthcare providers. Older
Depression is common in older adult patients. It often goes adult patients constitute a major part of general care patients
undetected and untreated. Depression lessens the ability of today. Healthcare professionals need to be sensitive to the
older adult patients to adapt to changes in lifestyle. Seemingly unique needs of this age group.
Social and economic risk factors
The social spheres that most affect a patient’s health behaviors Some cultures have lay healers, and the patient may wish
are: to combine the healer’s cures with medical treatment. Many
1. Family and significant others cultures view healing as a family affair; therefore, the family will
2. Relationships with healthcare providers always need to be present and involved in the patient’s care.
3. Cultural or ethnic groups Healthcare professionals must try to understand and appreciate
4. Religious community or beliefs the importance of these practices to help patients be adherent.
5. Economic status A significant concern related to nonadherence is limited income.
Patients are more likely to adhere with their treatment plans Patients may have hospitalization coverage but lack sufficient
if their family or significant others are supportive of it and funds to follow through on recommendations after discharge.
encourage them to follow it. They are also more likely to be A patient who must choose between feeding their family and
adherent if they have a positive relationship with their healthcare buying blood pressure medicine has no choice at all. This is
team, are included in the decision-making process, and are particularly true for older adult patients who are frequently on
acknowledged for being adherent. fixed, limited incomes. Choices between food and medication
are not easy ones, and healthcare professionals can help access
A patient’s cultural or religious beliefs and practices may prohibit as much assistance as is available to older adult patients. It is
adherence with a treatment regimen. In some religions, use of helpful to examine older adult patients’ finances with them and
certain types of medical interventions is regarded as a lack of plan realistic healthcare choices together.
faith in God, and those interventions are therefore prohibited.
Environmental risk factors
The healthcare setting can influence patient adherence. The are in the best position to use their skills to develop a care plan
most common factors are comfort issues and ease of access, with the patient that maximizes adherence. In the same way,
including transportation. The needs of patients who are knowledge of risk factors affecting compliance can enhance
physically impaired must be considered carefully. For example, discharge planning and make it more effective.
an older adult who has been directed to return to the clinic after Situational factors are best dealt with through anticipatory
a surgical admission may not keep this appointment. The patient planning. A conversation with the patient about the possibility
may not have transportation, the parking may be remote and of these events occurring and how to deal with them can ensure
require walking a long distance between the parking lot and their adherence. A patient on a restricted diet, for example, is
office, or the stairs may be too much to handle. If there is little asked to consider eating at home until they are familiar with the
to motivate patients’ return, then when they are feeling well, diet. The patient is also given ideas about what to order in a
environmental obstacles will result in nonadherence. restaurant that would be allowed on this diet. The patient may
Determining risk factors early in treatment enables healthcare feel uncomfortable explaining their diet to friends. Role playing
professionals to intervene effectively. Healthcare professionals can be helpful in these situations.
Case study 9
Bill is a 32-year-old, single African American man diagnosed with
bipolar disorder who stopped taking his medications 3 weeks Self-Assessment Quiz Question #11
ago. His family brought him into the emergency department The healthcare professional caring for this patient knows that:
because of his manic behavior. a. Most drugs for psychiatric illnesses have few side effects.
b. The severity of side effects for antipsychotic drugs varies
according to their gender.
c. A bipolar patient often stops taking their medication when
they are manic.
d. Medications for bipolar disorder have few side effects.

To avoid medication noncompliance in the future, the
healthcare professional should:
a. Limit disclosure of the severity of the illness to the patient
and family.
b. Encourage the patient to purchase needed medications at
their own expense.
c. Teach the family some of the symptoms (rapid speech,
change in energy level) that would show medication
nonadherence early.
d. Use scare tactics wherever necessary to obtain compliance.
The Diagnostic and Statistical Manual of Mental Disorders (5th detailed in this section. Of course, circumstances for any specific
ed.; DSM-5) diagnoses and the NANDA nursing diagnoses patient who is nonadherent may warrant additions to the listings.
that might be applicable to patients who are nonadherent are
Medication treatment nonadherence, as it is referred to in the ● Neurocognitive disorders.
DSM-5, can occur in patients with any diagnosis. However, ● Substance-related disorders.
especially for patients with psychiatric diagnoses, the effects ● Bipolar disorder.
of nonadherence can be unsafe. Patients with the following ● Schizophrenia.
DSM-5 diagnoses may be particularly at risk for nonadherence ● Feeding and eating disorders.
(American Psychiatric Association, 2013): ● Personality disorders.
The following are NANDA nursing diagnoses that are associated ● Coping (ineffective, defensive).
with patient nonadherence (Herdman & Kamitsuru, 2018): ● Family processes (e.g., dysfunctional, interrupted).
● Anxiety (e.g., mild, moderate, severe). ● Self-care deficit (e.g., bathing, dressing, feeding).
THE HEALTHCARE PROFESSIONAL’S REACTION TO THE PATIENT WHO IS NONADHERENT
Healthcare professionals’ willingness to examine their attitudes system’s approaches to patient care should be conducted (see
and feelings toward the patient is of primary importance in Box 1).
working with patients who are nonadherent. The identity of At times, healthcare professionals may feel unable to “allow” a
a healthcare professional is closely tied to the concepts of patient to be nonadherent. This situation might occur when the
helping, caring, and service. When a patient appears to reject healthcare professional has some commonality with the patient,
a healthcare professional’s expertise in promoting wellness, such as being the same age as the patient or having a parent
the healthcare professional must deal with many intense and who died of the disease the patient has. Healthcare professionals
conflicting emotions. who feel powerless in the face of a patient’s nonadherence may
Many healthcare professionals state that they would prefer to push the patient to adhere while assuming decision-making
spend their time with motivated patients who want to get well responsibilities that belong to the patient.
rather than with patients who do not comply with their treatment
plan. They express anger that the patients are “wasting” a Box 1. Cycle of Nonadherence Between Patients and
bed, precious resources, or the healthcare professionals’ time. Healthcare professionals
It is important to understand that many patients who are
nonadherent are not deliberately working against the treatment Depending on the reasons for nonadherence, the patient may
team. be quite happy to be left alone or to be overly dependent
on the healthcare professional. More likely, however, the
Sometimes anger can lead to withdrawal of services. A patient will feel that their real healthcare needs are going
healthcare professional may avoid going into the patient’s room undetected. This behavior may become a cycle.
or omit teaching the patient because “the patient isn’t going
to do it anyway.” The healthcare professional should deal with Nonadherence Cycle
these feelings in another way because it is obviously not helpful ● Patient is nonadherent
to punish the patient with these behaviors. Discussing the ● Healthcare professional feels angry, powerless, and so
patient’s case with the healthcare team and getting suggestions forth
for new approaches to handling the patient can be helpful. ● Healthcare professional withdraws or overreacts
Discussions may need to focus on the degree to which care is ● Patient’s needs go unmet
patient-centered, so that patients feel they are active, respected Healthcare Professional Strategies to Stop This Cycle
partners in healthcare decisions. Patients will resist interventions ● Becoming aware of feelings
if they feel that their needs are not being heard or respected. ● Performing a healthcare professional assessment
When they do resist and appear to be nonadherent, this may be ● Using care planning as a mutual process
a signal to the healthcare team that an internal assessment of the
INDEPENDENT HEALTHCARE PROFESSIONAL INTERVENTIONS
Healthcare professionals can be key players in enhancing do. Often patients are more likely to follow through on their
adherence on the part of their patients. By establishing rapport treatment requirements when they fully understand the reason
and creating trust, they present themselves to their patients and importance of what they are doing.
as informed and knowledgeable persons who can answer Patients benefit from the help of family and friends; healthcare
questions and offer ways to adhere to plans of care. Healthcare professionals can assist their patients in obtaining support from
professionals can reassure patients that it is not always easy these individuals. If there is a particular part of the treatment
to change long-term behaviors and gently reinforce why that goes against the patient’s belief system in some way, the
some changes may be necessary. Providing their patients with healthcare professional can help explain this to the healthcare
education as to the reason for certain treatment regimens team and together they (including the patient) can try to come
is something healthcare professionals are well equipped to up with an alternative intervention. Healthcare professionals
implement their role as a patient advocate when they assist in take it personally and react poorly in the situation. It is helpful
these situations. for healthcare professionals to examine their reactions and why
In addition to being professionals with a job to do, healthcare the patient may be acting in this way. Table 3 provides some
professionals are also individuals with their own belief systems. suggested healthcare professional interventions along with their
When patients are nonadherent, healthcare professionals can rationale for working with patients who are nonadherent.
Table 3. Independent Healthcare professional Interventions for Patients Who Are Nonadherent and Their Rationale
Independent Healthcare professional Interventions Rationale
Develop awareness of feelings toward patients who are If unaware of personal feelings toward patients who are
nonadherent with their treatment regimens. nonadherent, there is the possibility to be unaware of feelings of
anger and/or powerless toward patients. This may a withdrawal
from the patients and thus their needs will go unmet.
Develop a trusting relationship with patients. Trust is basic to a therapeutic relationship. The quality of the
healthcare professional-patient relationship has been shown to
be a powerful predictor of adherence.
Assess patients’ mental status. Several studies have shown that clinical depression is a risk factor
for nonadherence (Brown & Sinsky, 2017).
Explain clearly why the treatment is necessary and what to A complicated or demanding treatment plan is an ordeal for
expect (e.g., delayed benefits, general side effects). Ask the even the most motivated patients. Patients need to understand
patients to identify benefits of treatment, and how likely they why the plan is necessary; otherwise, they have little incentive to
think it is that there will be consequences of the current illness or follow through with it.
health problem (perceived susceptibility and perceived severity).
Include the patients in setting goals and planning care. The mutuality of expectations of patients and healthcare
Ask the patients to identify potential barriers to adherence (e.g., professionals makes it more likely that patients will be adherent
social, economic, or environmental factors). with the treatment plan. Encourage patients to ask questions and
express their concerns regarding their illness and the advantages
and disadvantages of a treatment regimen.
Addressing issues and strategizing with the patients as to how
best to deal with these issues will help with adherence and help
to reinforce the importance of the treatment plan.
Teaching should be aimed at the patients’ learning level. To be able to adhere, patients must understand the information
presented to them:
● Teaching should be brief and focused.
● Complex information should be broken into smaller, more
understandable parts whenever possible.
● Teaching material should be simplified as much as possible.
Aim for a reading level of fourth or fifth grade with few words
with more than three syllables.
Encourage patients to report problems with their treatment Patients often have valid reasons for not following a treatment
regimen, such as any unwanted or unexpected side effects, plan. The better the understanding of patients’ concerns about
before adjusting or stopping it. their treatment regimen, the more likely its importance will be
explained (Jones et al., 2015).
Encourage patients to request the support and help of family or If family members or other caregivers are not providing direct
friends. care to patients, and if patients are having difficulty following
through on taking medications or other therapies, family
members may be helpful in reminding patients to take their
medications.
Communicate concerns about the patients’ nonadherence with The healthcare team may detect and help solve nonadherence
other members of the healthcare team. Revisit the facility’s problems, including health system problems as well as patient
philosophy about patient-centered care. issues.
Patients do have the right to choose their own treatment educate patients so that they can make an informed choice and
and make their own decisions unless their choices will harm not to assume patients do not know what is best for themselves.
themselves or others. However, healthcare professionals and Walker (2017) outlined four basic philosophical orientations for
other clinicians may have a better knowledge base about clinician-patient relationships related to adherence.
treatment options. The healthcare professionals’ role is to
Paternalism
The paternalism model is based on the expertise of the clinician, This model is most acceptable in emergency situations and
coupled with a grounding in beneficence (the doctor or to value-neutral, technical decisions. There has been a shift in
healthcare professional knows what is best for the patient). This healthcare in recent decades toward more patient-centered,
framework often conflicts with the concept of patient autonomy. autonomous decision making.
The Radical individualism model
The patient has absolute autonomy and absolute rights of assessing alternatives, and healthcare staff members are
over decisions regarding their body. The patient is capable obligated to adhere with these wishes.
The consumer model
This relationship model is market based. Healthcare is seen as model tends to undermine the caregiver ethos by encouraging
a commodity with the patient as a consumer. This relationship emotional disengagement.

Shared Decision-making model
Also known as the reciprocal model or negotiated contract Holistic healthcare professionals, understanding the experience
model, the shared decision-making model lies between the from their perspective, work with the patient. They recognize
extremes of paternalism and radical individualism. It is rooted in that the burden of responsibility for the ultimate decision and
the concept of shared humanity in all participants. It emphasizes change belongs with the patient. The healthcare professional’s
the relationship to the patient, not the disease. duty is to educate and empower the patient.
Case study 10
Michael Longfellow is a 60-year-old male patient who was alcohol use disorder. With the information from that interview
admitted to the hospital after he fell and broke his hip. He had identifying Michael with a pattern of problem drinking, it was
been helpless at home for several hours after the fall because easier to approach Michael about his problem, and he was,
his wife was away from the house. When she returned and found in fact, assessed and referred for treatment of an alcohol use
him, he was immediately brought to the hospital by ambulance. disorder.
On the day of admission, surgical repair was performed. Questions
After surgery, Michael was disoriented for several days. He was 1. What are the staff’s issues regarding Michael’s nonadherence
confused, belligerent, and had visual hallucinations. Medication to his treatment plan?
for agitation was required some of the time. Michael’s blood 2. What are some approaches that the healthcare professionals
pressure and pulse rate were high. Eventually, his mental status can use when caring for patients who are nonadherent?
cleared, and the remainder of the postoperative period went
smoothly. Michael’s incision began healing, and his vital signs Discussion
became stable. 1. The evening staff healthcare professionals who described
the patient’s wife as cold and mean were clearly angry. If
Pain management, however, remained a problem for Michael;
they had examined their feelings closely, they might have
it was difficult to develop a pain management regimen that
enabled Michael to experience pain relief. He was unwilling to discovered that they were angry with the patient for his
practice coughing or deep breathing as recommended because unwillingness to participate in recovery. It is often easier to
of reported pain. It was a constant struggle to assist him with be angry at a healthy, and distant, family member than to
ambulation exercises, although he had been informed of the be angry with the patient. It can be difficult for healthcare
dangers from immobility many times. He developed pneumonia, professionals to accept their anger toward a patient who is ill
and his hospitalization continued. and with whom they interact on a daily basis.
His wife and adult children rarely visited and were unwilling It seems like the night healthcare professionals felt little
to talk with staff members. Michael reported that he had not compassion for this patient. They were most likely dealing
worked for years and relied on his wife for much of his care and with feelings of powerlessness. Michael was a patient who
support. He gave vague reasons for this situation, stating that ignored the rules and the healthcare advice offered to him.
he had been laid off and that there were never any jobs in his Powerlessness is difficult for anyone to experience and is
field of employment. most often masked by anger and rejection. When staff learn
The healthcare professional staff began to be concerned how to use techniques of brief assessment and intervention
as time passed and Michael did not appear to be assuming with patients who have alcohol problems and see their role
responsibility for his recovery. He, on the other hand, was in patient-centered care more clearly, they will feel less
eager to return home and pressured his physician to let him powerless.
go prematurely. The staff called a patient care conference to Most of the issues of nonadherence in this case study may
discuss the discharge plans for Michael. be attributable to the patient’s unrecognized alcohol use
During the conference, several of the healthcare professionals disorder. Michael was unwilling to adhere to treatment
on the evening shift expressed concern that Michael would not recommendations because of his as-yet-untreated alcohol
be well taken care of if he were to return home at this time. use disorder. His wanting to leave the hospital may be, in
They had met his wife because she visited in the evening after large part, motivated by his desire to have easier access
work. They described her as “cold” and “mean.” They were sure to alcohol. If he had been discharged to home without
that she would provide no assistance to Michael, who would be treatment of this problem, his chances of a successful
forced to fend for himself at home. recovery would have been low. In addition, his alcohol
The night healthcare professionals described ongoing use would have placed him at risk for more falls and other
episodes of insomnia that the patient had experienced since physical problems.
his admission. One of the healthcare professionals had found
Michael attempting to smoke in his room. She stated that he In this example, the staff needed to learn to look beyond
drank cup after cup of coffee whenever he could. She thought Michael’s nonadherent behavior and find out what was really
that he was simply a patient who was nonadherent with his occurring. He was certainly not following the treatment plan,
treatment plan and should be discharged as soon as possible but it was not simply negativity. There was an unidentified
with home care assistance. problem beneath the surface that needed resolution before
Michael could address his nonadherence.
One of the healthcare professionals mentioned the possibility
that Michael might have an alcohol use disorder. She cited his Family issues in this case study should not be overlooked.
delirious episode after admission, his low pain tolerance, and The wife and adult children should be included in
the dysfunction in the family as possible indicators that he might discussions, with some focus on their own possible health
have a substance use problem. The physician added that the issues, needs, and feelings as well. Further assessment and
hypertensive episode after surgery and the insomnia supported referral may be appropriate for the entire family. Because
that assessment. adherence to the treatment plan will be critical for a
The social worker remembered that Michael’s wife had bitterly successful outcome for Michael, paying attention to family
discussed with her Michael’s lack of employment and his issues interfering with adherence is important.
previous falls. The social worker admitted that she had focused 2. Much of the time, the healthcare team is asking the patient
on the wife’s hostility instead of on the possibility of an alcohol to make significant changes in a lifelong pattern of behavior.
use disorder. She added that the behavioral habits of smoking This is not easy for anyone. Creating attainable short-term
and excessive coffee drinking have been linked in the literature
goals for which the patient can experience success is helpful
to problem drinking.
in ultimately reaching long-term goals. The healthcare
It was agreed that the social worker would meet again with professional provides thorough and appropriate education
Michael’s wife and discuss the possibility that Michael has an and training on any aspect of the patient’s care plan to
enhance cooperation with the recommended treatments and is likely that situations will arise when the patients’ problems
interventions. Use of Internet or smart phone resources can match ones that healthcare professionals, themselves,
help remind and educate the patient. Teaching family and are experiencing. Self-awareness is critical for successful
friends to be alert for signs of changes in behavior is part of interactions in these situations. Healthcare professionals
a holistic approach. Establishing a strong sense of rapport is are not perfect, and they may have unsolved problems and
essential to teaching being effective. issues, but knowing what they are is important.
It is also useful to discuss with the patient why adherence There is also the recognition that patients do have the right
is difficult for them. Finding the root of the problem and to nonadherence. Sometimes the patient is making choices
addressing it directly can help with optimizing the patient’s for reasons the healthcare professional has not considered.
ability to carry out the plan of care and achieve the desired It is essential to examine why the patient stopped (or never
health benefits. For example, the patient may not remember started) the treatment as prescribed. There is also a time
to take a prescribed medication because it is effectively when patients will have to live with the consequences of their
working and there are no symptoms triggering the need to own actions. The self-aware healthcare professional knows
keep taking the drug. The healthcare professional can assist that there are limits to what teaching and explaining can do
the patient with finding other reminders as to when the to change the health behaviors of others.
medication should be taken. Many people have cell phones
equipped with alarm features, so teaching the patient how Evidence-based practice! Some technology-based
to use this alarm function may be a constructive way to gain interventions, such as reminder apps on a cell phone or digital
adherence to medication use. patient education are becoming more common, but do they
Healthcare professionals who acknowledge their own really work? Some clinical trials have been examining the
effectiveness of smart phone reminders and education for
problems make it less likely that those problems will interfere
mental health patients. One meta-analysis (Linardon & Fuller-
with helping the patient. Healthcare professionals, just like Tyszkiewicz, 2020) examined numerous clinical trials, and the
patients, may find it difficult to follow many health-related adherence and improvement in behavior was not consistently
behaviors. Adherence on the healthcare professionals’ part improved. Mental health patients often drop out of programs
helps patients see congruence in what is practiced by others or trials, and low levels of adherence are seen as common for
and what is asked of them. However, examining their feelings this population. Healthcare professionals can only continue to
is not always the easiest thing for healthcare professionals to offer education and support for the patient and their family.
do. Because patients present with many different issues, it
MANIPULATIVE BEHAVIORS
Illness poses a severe threat to a person’s security, self-esteem, anxiety may prompt a regression to manipulation as a coping
and autonomy. It results in a loss of self-control and a fear of mechanism even in patients who do not typically demonstrate
becoming helpless and dependent. The healthcare system manipulative behaviors.
may also place patients in childlike positions. The resulting
A DEVELOPMENTAL VIEW OF MANIPULATIVE BEHAVIORS
Before healthcare professionals can intervene effectively, they As children grow and develop, they test a variety of adaptive
must understand not only what manipulation is and how they maneuvers to manipulate the environment to gratify their needs. If
respond to it but also where it begins. How does manipulation a child’s unacceptable behaviors are met with clear and consistent
become entrenched as a need-gratifying mechanism? limits delivered by primary caretakers with unconditional love and
The use of manipulation as an adaptive, need-gratifying acceptance (of the child if not of the behavior), then the child will
mechanism starts early in life. It is defined as an automatic gradually develop a sense of self-esteem and self-control. Slowly,
behavioral pattern that infants use to get their basic needs met. children learn to replace manipulation with more independent,
They manipulate without any regard for the needs of others. adaptive behaviors.
In newborns, who are utterly dependent on others, the use of If, on the other hand, a child’s first limit-testing manipulative
manipulation is acceptable and, in fact, vital. It is a matter of efforts are met with inconsistent limits or with no limits at all, with
survival. conditional love, and with lack of acceptance of the child, then the
child will not learn how to fulfill their needs and how to gain love
and acceptance from others (Townsend & Morgan, 2017).
ADAPTIVE MANIPULATION VERSUS MALADAPTIVE MANIPULATION
Manipulation, learned early in life, is a process that occurs Unquestionably, the word manipulator has taken on a derogatory
consciously or unconsciously in virtually all interpersonal or pejorative connotation. However, the fact is that everyone
interactions. manipulates at times as a way of ensuring that needs are
When manipulation is used in an adaptive sense, it is just one met. It is important to understand that isolated instances of
of many behaviors that a person can call on to ensure that their manipulation do not make a person a manipulator. It is when
needs are fulfilled. It is neither the only need-gratifying behavior manipulation as a need-gratifying mechanism becomes an
nor the dominant one. adult behavioral pattern that it is viewed negatively. When it is
adopted as the primary means of decreasing anxiety without the
For manipulation to be considered maladaptive, it depends on the opportunity of learning or experiencing personal growth, then it
● extent to which it is used as a dominant need-gratifying is problematic.
mechanism.
● degree to which a person is aware of using it.
● degree to which the person is self-oriented and not oriented
to others.
● degree to which others are treated as objects.
● effect on others, such as the person who has been
manipulated feeling angry but not necessarily being certain
as to why.

Healthcare Professional Consideration: For the same reasons younger patients are prone to manipulation, anxiety, lack of control
in their environment, low self-esteem, and feelings of insecurity, the elderly are also likely to use such behavior to meet their needs.
Although healthcare professionals working with geriatric patients may understand why it is happening, it is no less frustrating to
manage. It is important for the healthcare professional to provide information to this population about reasonable expectations and
then make every effort to meet those expectations. If something has been promised that cannot happen, the healthcare professional
should explain to the patient why this change must be made. Open and honest communication is important in establishing trust and
modeling straightforward behavior. One healthcare professional (Kemerer, 2016) notes that consistent therapeutic communication
and remaining accountable serve to decrease the likelihood of allegations of neglect or abuse.
IDENTIFYING MANIPULATIVE BEHAVIORS
Healthcare professionals may overuse the term manipulative. fresh beverage is understandable but asking for another within
After a difficult day or after caring for a string of patients with an hour and then needing more ice, then a pain pill, and then
particularly taxing behaviors, a healthcare professional may be wanting to have a pillow fluffed becomes too much (Riley, 2020).
prone to assign the label manipulator to the patient who makes Healthcare professionals who work in correctional or psychiatric
that one final demand that sends the healthcare professional settings often experience this manipulation as a stressor
over the edge or to the patient who is just a little too insistent (Schoenly, 2017). If the term manipulative is to have clinical
in their self-advocacy. Patients who use manipulation have meaning, its characteristics must be understood.
many requests that begin to seem unreasonable. Asking for a
Manipulation is not always easy to recognize
Patients who use manipulation are often charming, entertaining, a superego (concerned with moral behavior) strong enough for
and intelligent. They rarely see themselves as having a problem pangs of conscience to be genuine.
and are unlikely to seek help on their own. In fact, many The reaction of healthcare professionals faced with such
individuals who demonstrate manipulative behaviors are loathe situations is, understandably, negative. It is sometimes possible
to change even when confronted because these behaviors get to detect manipulation by virtue of a negative reaction to a
their needs met (Townsend & Morgan, 2017). When the harmful patient’s interaction or request. Sensing that something does
effect on others is pointed out, these patients may feign guilt not ring true can assist the healthcare professional to suspect
or remorse because they are aware that these are the socially manipulative behavior. Universally, healthcare professionals, like
acceptable responses. They will not actually feel those feelings, most of the population, want to avoid interaction with patients
however. Patients with dominant manipulative traits do not have who regularly use manipulation.
Cycle of manipulation
A person has needs to be met but cannot trust the environment pathology of manipulation. The patient who uses manipulation
to meet them consistently. The ensuing anxiety causes the in a maladaptive way has little concern for the wants and needs
person to fall back on the earliest need-gratifying mechanism of other people. Because individuals who use manipulation do
– adaptive maneuvering and manipulation to ensure that their not trust their own feelings, they cannot trust others. This lack of
needs are met. If the manipulative behavior is effective, then the trust leads to a sense of loss of control, and the individual tries to
anxiety temporarily decreases. The person’s needs have been regain a sense of self-mastery by controlling others.
met. However, the pattern of manipulation has been reinforced.
When the same person gets a negative response, they may Evidence-based practice! There are a variety of measurement
become angry and frustrated, and anxiety skyrockets. The tools available to attempt to decipher personality traits.
person again tries desperately to manipulate the environment in Exploring manipulative behavior is of interest to many,
an effort to regain control. The pattern is set, especially when the especially because of its apparent connection with delinquent
manipulative behaviors work. and/or criminal behavior later in life. Bergstrom and Farrington
(2018) investigated whether the use of one or more scales
Lacking basic trust, the person is caught in an endless cycle of could be predictive of psychopathology in adulthood. The
having to resort to manipulative behaviors to ensure that their data were supportive of a connection between high scores
needs are met. In the process, however, individuals are likely to on callous-unemotional traits combined with high scores on
alienate those around them and generate mistrust from other daring-impulsive ones pointing to a higher risk in childhood
people. The issue of this loss of trust is key to understanding the and outcomes as adults that were below normal.
THE HEALTHCARE PROFESSIONAL-PATIENT CYCLE OF MANIPULATION

The patient who exhibits manipulative behaviors is uncannily ● Ingratiating and flattering: “You’re the only one on this unit
adept at seeking out the unique weaknesses and vulnerabilities who can possibly understand me. I don’t even know why
of others and using those weaknesses and vulnerabilities to gain you’re working here – you’re so much smarter than the rest of
control. Their manipulative behavior can be active or passive. them. And prettier too.”
Active manipulation may involve any of the following behaviors: ● Evoking guilt feelings: “Well, if you had come in here to talk
● Making demands: “I want my medication at 9 o’clock, not 8 to me at 2:15, when you said you would, I wouldn’t have
o’clock. I don’t care about your rules!” gotten so depressed, and I wouldn’t have had to cut my
● Violating rules and routines: “Oops! I forgot I was supposed wrist.”
to be measuring my urine. Guess I’ll need to stay another day ● Abusing compassion: “You said you understood how hard
so you can get a complete sample.” it was for me to be in this hospital, so I was sure you’d
● Making threats: “If you don’t get that guy and his obnoxious understand why I needed to sneak out this morning. I’m back
family out of my room this minute, I’m going to tear up this now, so take it easy. Why do you have to search me? You said
place – and you along with it!” you trusted me!”
● Attempting to exchange roles and become the helper’s
helper: “I heard you tell one of the healthcare professionals
that you’re having trouble with your son. I can’t believe he
Manipulative behaviors can also be passive and more subtle: doesn’t appreciate having a mother like you. I’m about his
● Eliciting pity: “Can’t you understand how hard it’s been for age, I’ll bet. Tell me what he’s doing. Maybe I can help.”
me lately? My husband is leaving me for another woman, ● Pitting staff members against each other: “I couldn’t get that
my two kids are out every night until 1:00 a.m., and my son other healthcare professional to understand why she should
wrecked a brand-new car last weekend. Wouldn’t you drink persuade the doctor to discharge me tomorrow. She said not
too?” to discuss it with you because you’re too new to understand
the rules yet. But I know you understand my situation. Will If healthcare professionals are to stop the cycle, self-awareness
you explain it to my doctor? And pick a time when she’s not is vital. If they have difficulty with their own self-esteem, they will
around to interfere.” be vulnerable to manipulative behavior. The key is for healthcare
● Questioning competence or authority: “My doctor said professionals to be aware of their needs so they will know when
that I could have another sleeping pill if the first one didn’t they are being exploited. They also need to be aware of their
work. Can’t you even read a chart? Well, you’re not in charge own responses, such as feelings of anger, need to withdraw,
around here anyway. We’ll see what happens to your job frustration, or loss of objectivity, as indicators that they are being
when the unit manager comes in tomorrow.” manipulated. Only then can they be effective in helping patients
In each of the foregoing examples, patients seized on a find more adaptive ways of getting their needs met.
particular need of the healthcare professional (the need to
be professionally competent; to maintain a safe, consistent Table 4. Ten Steps to Setting Limits with Patients Who
environment; to be viewed as empathic and understanding) and Exhibit Manipulative Behaviors
geared their behavior to exploit the healthcare professional’s 1. Define clear expectations.
weaknesses or therapeutic vulnerability. 2. Communicate expectations positively and firmly.
When healthcare professionals realize they have been 3. Limit only those behaviors that clearly impinge on the well-
successfully manipulated, their likely response is a range of being of the patient or others.
4. Make sure that the limits are in the patient’s best interests
negative feelings and behaviors, including anger, frustration, and are not punitive.
indifference, and withdrawal. Although patients with 5. Offer a brief rationale for the limit but do not engage in a
manipulative behaviors will enjoy these responses as signs of debate about its fairness or justification.
their power, they will also feel an inward sense of increasing 6. Define the consequences of exceeding the limit, and make
anxiety because once again they have successfully managed to sure that they are consequences that can be fulfilled.
manipulate someone. Can no one be trusted? Will no one ever 7. Hold all discussions related to limit setting on a one-to-one
be able to see through them and give them what is truly needed basis, in private. (This limits the opportunity for the patient
– a sense of realistic limits and a genuine feeling of self-control? to involve an “audience” in determining whether the limit is
The vicious cycle of manipulation can play out repeatedly “fair.”)
between healthcare professional and patient when manipulative 8. Make sure that all staff members understand the limit and its
behaviors are not accurately identified, and healthcare consequences as they were communicated to the patient.
professional interventions are not put in place to halt the cycle. 9. Stand firm in the face of the inevitable testing of the limit.
It is essential that firm, realistic limits be set and then followed 10. Provide positive reinforcement every time the patient is able
with all patients. The limits should be communicated clearly and to meet the limit.
openly, with an appropriate rationale. Although there should be Based on Reach, G. (2016). Patient education, nudge, and manipulation:
consequences for nonadherence, they should not be punitive Defining the ethical conditions of the person-centered model of care.
but should be set to reflect the best interests of the patients. Patient Preference and Adherence, 10, 459-468. https://doi.org/10.2147/
Table 4 summarizes steps that are helpful in setting limits for PPA.S99627; and Townsend, M. C., & Morgan, K. (2017). Essentials of
patients who act in a manipulative manner. psychiatric mental health nursing: Concepts of care in evidence-based
practice (7th ed.). F. A. Davis.
The following are the Diagnostic and Statistical Manual of Mental behaviors. Of course, circumstances may warrant additions to
Disorders (5th ed.; DSM-5) diagnoses and North American the list of diagnoses for any specific patient, but those listed
Nursing Diagnosis Association (NANDA) nursing diagnoses that here are likely for anyone with manipulative behaviors.
might be applicable to patients who demonstrate manipulative
As noted earlier, manipulative behaviors are ubiquitous. professional assigned to a patient with one of the diagnoses
Healthcare professionals may encounter manipulation in any in this list should be on the alert for manipulative behavior.
patient, on any unit, and in any circumstance. However, patients However, it would be an error to rely on the DSM-5 diagnoses as
with the following DSM-5 diagnoses are more likely than others a sole indicator.
to show characteristics of manipulation (American Psychiatric Many patients who have one of these diagnoses may not be
Association, 2013): maladaptively manipulative. The opposite is also true. Many
● Conduct disorders patients who do not fit one of these diagnostic categories may
● Feeding and eating disorders use manipulation as a primary need-gratifying mechanism.
● Personality disorders A thorough healthcare professional assessment will help
● Factitious disorders the healthcare professional identify manipulative behaviors
● Substance use disorders regardless of the patient’s diagnosis.
These DSM-5 diagnoses provide “red flags” to the possibility of
the use of manipulative behaviors by patients. Any healthcare
The NANDA nursing diagnoses that are most often associated with ● Self-esteem (e.g., chronic low, situational low, risk for low)
manipulative behaviors are the following (Herdman & Kamitsuru, ● Anxiety (e.g., mild, moderate, severe)
2018): ● Fear
● Impaired social interaction ● Risk for loneliness
● Coping (e.g., ineffective, compromised family, defensive)
INDEPENDENT HEALTHCARE PROFESSIONAL INTERVENTIONS
Patients who use manipulation as a means to have their needs meaningful relationships. The healthcare professional who
met present a challenge for healthcare professionals. Patients can help patients recognize the effects of their manipulative
may be unable and unwilling to recognize their maladaptive behavior and find alternative need-gratifying mechanisms will
manipulative coping mechanism. Even when the healthcare do much to improve their patients’ quality of life. Role-modeling
professional points it out, the patient may not be willing straightforward behavior is an effective way to encourage
to change. As noted previously, manipulation is inherently patients to lessen their manipulative behaviors.
rewarding. However, manipulation also has a way of alienating
others and making it impossible for the patient to form

Gaining the patient’s trust, although difficult, and sometimes patients who use manipulative behaviors will try their best
not possible, is something the healthcare professional should to gain power by undermining the healthcare professional’s
work toward. Trust-building behavior includes being on knowledge, skill, and competence.
time for treatments or other appointments with the patient, Consistency will help gain rapport with patients using
never promising something that cannot be delivered, and manipulation. All staff members must agree on a plan and follow
remembering things the patient has related. In addition, through with it. Individually, healthcare professionals must remain
healthcare professionals must accept that patients may say consistent day to day in their expectations and responses. See
hurtful things and not take them personally; patients who use Table 5 for healthcare professional interventions that may be
manipulation make such remarks to everyone. Self-confidence useful in caring for patients who use manipulative behaviors.
on the part of the healthcare professional is important because
Table 5. Healthcare Professional Interventions and Rationale for Managing Patients’ Manipulative Behaviors
Independent Healthcare Professional Interventions Rationale
Establish a trusting relationship. Establishing a trusting relationship is as difficult as it is vital.
● Deception is a way of life for the patient who uses manipulation, but
every healthcare professional intervention is based on the foundation of a
trusting healthcare professional-patient relationship.
● It may be the first trusting relationship that the patient has ever had in
their life. Allow time for trust to develop.
Help patients recognize their manipulation and Patients cannot be helped to find more adaptive ways of living if they do not
potential causes of their behavior. recognize their current behavior as a problem and take responsibility for the
circumstances in which they find themselves.
Provide a consistent environment. Inconsistent caretaking is at the root of the development of maladaptive
manipulation as a coping mechanism in early childhood.
● The goal of manipulation is to somehow make the environment safe and
secure.
● Knowing what to expect decreases the patient’s anxiety and helps them
learn to trust others and the environment.
● In addition, consistency reduces the patient’s opportunity to divide the
staff by manipulating them.
Formulate short- and long-term goals to ensure that Consistency is vital to ensuring that the patient cannot manipulate by
every member of the staff carries out the care plan “splitting” the staff – all team members should provide input in setting goals.
as consistently as possible. Short-term goals include the following:
● Recognize and verbalize feelings of anxiety, frustration, or powerlessness.
● Recognize instances of manipulative behavior.
● Gain insight into the effect of manipulative behavior on others.
● Distinguish between wants and needs and learn to delay immediate
gratification of both.
● Verbalize acceptance of responsibility for own actions.
● Limit manipulative behavior and determine and practice alternative
methods of gratifying needs.
Long-term goals include assisting the patient to achieve the following:
● Determine and express needs in a clear, direct manner that does no harm
to others.
● Demonstrate responsibility for their own actions.
Recognize and refuse to respond to manipulation. Refusing to support the manipulative behavior tells patients who are
manipulative that you the healthcare professional cannot be used as an
object. They will have to find another way to get the healthcare professional
to meet their needs.
Do not accept the behavior but accept the patient. Patients who manipulate are in desperate need of acceptance and positive
regard. The healthcare professional should recognize the patient’s behavior
as manipulative rather than label the patient as a “manipulator.”
Help the patient to understand the impact of their Do not assume that empathy comes naturally to patients who manipulate.
behavior on others. Help them develop an awareness of their impact on others by being honest
about how it feels to be manipulated.
Set limits that are reasonable, clear, firm, and Although patients will most likely rail against limits, they will be enormously
consistent. relieved by them. Limits will provide the external control patients need until
they can develop internal control.
Provide positive reinforcement every time the The patient needs to recognize not only unacceptable behavior but also
patient is able to: acceptable behavior. Reinforcement of positive behavior is likely to elicit
● communicate needs directly, more of the same.
● take responsibility for their own actions, or
● accept limits.
American Nurses Association, American Psychiatric Nurses Association, & International Society of Psychiatric-Mental Health Nurses. (2014). Psychiatric-
mental health nursing: Scope & standards of practice (2nd ed.).
Townsend, M. C., & Morgan, K. (2017). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (7th ed.). F. A. Davis.
Manipulation tactics can include flattery, interest, or praising professional will be the only healthcare professional who can
one healthcare professional while degrading another healthcare care for the patient, then the patient will refuse to see that
professional. This attempt at control is usually the means to an healthcare professional (Schoenly, 2017). Reflection on each
end; there is some goal in mind for power, entertainment, or experience with a fellow team member can be helpful for
privileges. Manipulation is so prevalent in some settings that healthcare professionals. Meeting frequently to ensure all staff
healthcare professionals have developed theories and strategies members (even non-healthcare professional staff) are applying
to better manage the difficulties associated with these patients’ the same rules to patients who manipulate is recommended.
behaviors (Schoenly, 2017). It is critical to understand that the underlying aspect of this
Intentionally developing social maturity, which includes personality trait is stable and enduring. It is difficult to change
the emotional strength and ego to recognize and deflect a pattern of behavior, but consistency and a caring and
manipulation, is an important goal for healthcare professionals. professional approach must be maintained to begin to make a
Healthcare professionals’ benefit from learning to recognize change.
intrinsic rewards such as knowing they have made a difference The management of “difficult” patients leads to frustration,
and helped someone else transcend to a higher level of stress, and burnout for healthcare professionals. The team needs
functioning. For patients who use manipulation, healthcare to work cohesively and reflectively and offer support to all team
professionals must clearly set the healthcare professional-patient members. Training to work with patients who use manipulation
relationship with appropriate professional boundaries and will reduce burnout and increase job satisfaction, while
maintain those boundaries (Schoenly, 2017). continuing to provide care to all those who need it. Mentoring
Patients often use a combination of charm and manipulation healthcare professional colleagues is highly recommended for
to disturb the flow of care on a healthcare professional unit. situations involving patients with manipulative behaviors.
These patients can be difficult. One moment one healthcare
Case study 11
David Andrews, a single, 32-year-old White man, has been
admitted to the general surgery unit for a hernia repair. His Self-Assessment Quiz Question #13
healthcare professional, Bonnie Blake, introduces herself and How should Bonnie interpret David’s last remark?
welcomes him to the hospital. Bonnie is a recently divorced a. David is probably very nervous about being admitted to
28-year-old and has been a registered healthcare professional
the hospital.
(RN) for about 6 months. She explains to David that she will
need to ask a series of questions, some of which he may already b. David is a big flirt.
have answered, but that she would like to hear his answers c. David is probably guilty of sexual harassment in his work
herself. David says he will be very happy to answer questions situation.
asked by such a cute healthcare professional. He tells Bonnie d. It is hard to be sure of how to interpret his remark at this
that he hopes she is his healthcare professional the whole time point.
he is in the hospital and will meet his “every need, if you get
what I mean!”
Case study 12
Bonnie begins her assessment by asking David ordinary
questions such as his name, address, date of birth, and marital Self-Assessment Quiz Question #14
status. Each time he answers, David adds a short comment Which would be the best response for Bonnie to make to
such as, “Yes, I already answered that one” or “Seems like you David’s comments?
people could pass along information better; are you people all a. “I told you these questions may have already been asked.”
incompetent?”
b. “I agree that all this makes things very repetitious.”
c. “I do understand your frustration, there aren’t too many
more items.”
d. “I really wish you’d stop interrupting, then we’d get done
sooner.”
Case study 13
When asked the question about marital status, David replies,
“I’m single, who wants to know?” and gives Bonnie a wink. He Self-Assessment Quiz Question #15
then asks her what her marital status is. What is the best response for Bonnie to make at this point?
a. “That’s really none of your business.”
b. “Hey, I’m asking the questions here!”
c. “That is not the purpose of this interview.”
d. “If I tell you, will you start just answering what I ask?”
Case study 14
Bonnie is becoming increasingly uncomfortable and decides she about it. Although David is cooperating by answering the
needs to take a short break from this interaction. She tells David questions, he is making remarks that undermine Bonnie’s
she needs to check on something and will be back as soon as confidence in her ability to provide competent care. He
she can. As she leaves the room, David calls out, “You hurry is putting their relationship on a personal, rather than
back, you sweet thing, I’ll miss you while you are gone!” professional, level, and is treating her as a potential date,
Questions not his healthcare professional. As a new RN, it is normal
1. Why is Bonnie feeling so uncomfortable? that Bonnie does not yet have complete confidence in her
2. Why is David behaving the way he is? abilities. On top of that, as a recently divorced woman,
3. Is Bonnie making a good decision to “take a break”? she possibly has doubts about her desirability as a woman.
Discussion Because his behavior is inappropriate for the setting, Bonnie
1. More than likely, Bonnie is uncomfortable because David cannot be sure what David means by his flirtatious remarks;
is behaving inappropriately, and she is unsure what to do does he actually find her attractive, or is he teasing her?

With the ambiguity and Bonnie’s lack of experience, it is not behavior, David will have difficulty getting his needs met
unusual that she would become anxious in her interaction in this manner. Instead of gaining the support and help he
with David. needs, he alienates people and causes them to avoid him.
2. David may be nervous about having to be admitted to the 3. Given the fact that Bonnie is becoming extremely anxious
hospital. The behavior he is exhibiting might demonstrate and feels like she is losing control of the interview, taking a
an attempt to gain control of an unfamiliar situation. He is break is not an inappropriate decision. Although there are
manipulating his healthcare professional in such a way that other ways to deal with the situation, Bonnie has found a way
gives him the upper hand, in his opinion at any rate. Or to interrupt the seemingly downward turn that the interaction
David might simply be used to this sort of interaction under was taking.
any circumstance. Whatever his reasons for this manipulative
Case study 15
Bonnie finds her supervisor and tells her that she is very
uncomfortable with David. She asks if she can be reassigned Self-Assessment Quiz Question #16
to a different patient and let Joe, another RN on the unit, take On hearing her supervisor tell her that she will continue as
over for her with David. The supervisor tells Bonnie that it would David’s healthcare professional, Bonnie’s first reaction is to
be better if she learned to manage patients with manipulative plead her case and ask her supervisor to reconsider. What is
behaviors and that, for now, the assignments remain as they are. the supervisor’s best response?
The supervisor does spend a bit more time with Bonnie and asks a. “Tell me more about your feelings of discomfort.”
her what, specifically, is making the interview so uncomfortable
b. “All new healthcare professionals are a bit uncomfortable
and what she thinks would be the best thing to do about her
discomfort. at first.”
c. “No, I can’t reassign you to another patient.”
Question d. “What if everyone wanted to switch assignments?”
Is the supervisor making the right decision in having Bonnie
continue to work with David?
Discussion Self-Assessment Quiz Question #17
At least for the present, the supervisor seems to be making the Which of the following would be the best way to resume the
right decision. Bonnie will encounter all sorts of people in her interview once Bonnie has returned to the assessment room?
career as a healthcare professional and will not have the luxury a. “Sorry for the delay, let’s start where we left off.”
of changing assignments every time she is uncomfortable with b. “OK, David, let’s try to stay on track now that I’m back.”
one of them. She needs to develop the skills to work effectively c. “I’m back to continue where we left off – if you can
with all types of behaviors exhibited by patients. Given his cooperate by simply answering my questions.”
manipulative behaviors the patient has made her uncomfortable, d. All right, we’ll continue with your assessment. I hope you
but her supervisor sees this as a good learning experience can avoid any more inappropriate remarks.”
and offers support by talking over the difficulties Bonnie is
encountering.
Conclusion
Healthcare professionals should never underestimate the can avoid potentially violent situations and work with difficult
potential for violence; assaults by patients – young or old, patients by being prepared and recognizing the signs and risk
male, or female – can occur for many reasons. This course factors for these occurrences. It also explores how healthcare
explored how healthcare professionals will encounter difficult professionals must deal with their own feelings toward difficult
or hard to manage patients during their career, including patients while treating them. De-escalation skills, diagnosis,
workplace violence, non-adherence to medical treatments, preventative measures, training, and planning are all presented
and manipulation of caregivers and the treatments and skills in this course to help healthcare professionals respond to difficult
needed. This course demonstrated how healthcare professionals patients and ensure a healthy and safe environment.
Glossary
Adherence: The term adherence describes the degree to Compliance: The term compliance is used to describe the
which a person’s behavior corresponds with the agreed degree to which patients follow their healthcare providers’
recommendations from a healthcare provider. Adherence recommendations. It implies a patient-healthcare provider
acknowledges that the patient is part of the decision-making hierarchy, or a power differential in the relationship, in which
process. To promote adherence, hospitalization must become an the patient is relegated to a subordinate role. Some healthcare
experience in which patients maintain control over most of what professionals believe this has a negative influence on patient
happens to them. Healthcare providers are finding new ways compliance with the healthcare provider’s recommendations.
to alleviate the dilemmas that patients face when hospitalized. Noncompliance: The North American Nursing Diagnosis
An example is the patient-controlled analgesia pump for self- Association (NANDA) definition of noncompliance is when the
administration of pain medication. Use of this device reduces the actions of the patient do not follow the health-promoting or
patient’s dependence on the healthcare professional for comfort therapeutic plan agreed on with the healthcare team (Herdman
and, in many cases, reduces anxiety about pain control. & Kamitsuru, 2018). A plan of action for involvement and
agreement with the management plan is needed.
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MANAGING DIFFICULT PATIENTS FOR HEALTHCARE PROFESSIONALS

1. The correct answer is D. 10. The correct answer is D.
Rationale: The important thing is to get the medication in the Rationale: Preventing harm to the patient and staff and
patient quickly. providing a safe environment is important. This is precisely what
the nurses and other staff in this scenario did. They focused on
the needs at hand and implemented appropriate interventions
Rationale: Martha will likely feel like a failure because her
based on the observed behavior.
supervisor had to give the injection. Susan can explain to Martha
that it is difficult to ignore some of what she was taught in 11. The correct answer is C.
school, even in emergency situations. Susan shares that with Rationale: Patients who are experiencing mania feel highly
more experience, it is easier to do this simply because she has energized and motivated during this phase of their illness.
given “millions” of shots and can better determine where to They believe they feel well, although they often have anxiety
place the needle from her experience. and inappropriate behaviors such as compulsive spending or
numerous unfinished products.
Rationale: While Astrid is available, it would be important for 12. The correct answer is C.
Jackie to get this information from her. Asking Erik directly Rationale: As much teaching as possible is needed for both this
about his “mood swings” and informing the doctor about what patient and his family. It would not be unusual for a patient to
Astrid reported are actions Jackie could take later. try to hide the nonadherence to medications prescribed from his
family.
Rationale: Even though Erik is sleeping now, it does not 13. The correct answer is D.
eliminate the possibility that he might become disturbed. Rationale: Any of the other responses might be true, but it is a
little early to make any definitive judgments.
Rationale: This is a situation that needs attending to as soon as 14. The correct answer is C.
possible and it may take more than one person to handle it. Rationale: Answer c acknowledges that the process is
cumbersome without taking sides or “scolding” David.
Rationale: Although all actions are needed, the priority is the 15. The correct answer is C.
safety of Erik and the staff. Getting other staff to the room to Rationale: Answer c is the appropriate response so as not to be
help calm Erik would most quickly accomplish that goal. rude or flirty or create a bargaining situation.
7. The correct answer is C. 16. The correct answer is A.
Rationale: Stating the facts about the situation first followed by Rationale: This will help Bonnie to focus on the feelings she is
letting Erik know the staff are there to help calm him will not having about the situation and, hopefully, what is at the root of
come across as accusatory or belittling to Erik. her discomfort.
Rationale: This approach provides Erik with an opportunity to Rationale: At least to begin with, it would be best for Bonnie
tell the staff in his own words what has been bothering him. to start with a clean slate and not address David’s previous
behavior. If it continues, then Bonnie will need to say something,
but it would be best to first wait and see how things progress
Rationale: Jackie is seeking answers to help her understand
from the new starting point.
Erik’s behavior. At this point, there is not a definitive answer to
Jackie’s question. The interventions in plan will help the team to
gather more information to better understand Erik’s behavior.
Course Code: ANCCNC05MP22

Mindfulness for Healthcare Professionals
3 Contact Hours
Release Date: June 7, 2021 Expiration Date: June 7, 2024
Faculty
Author: Christina B. Jackson, PhD, APRN, APHN-BC, received spoken about applying yoga, cognitive behavioral techniques,
both her Bachelor of Science in nursing and Master of Science and other mindful self-care and patient-care strategies to
in Nursing with pediatric nurse practitioner specialty from the healthcare professionals. Dr. Jackson holds certifications in Yoga,
University of Pennsylvania and her PhD in interdisciplinary Pilates, Hypnotherapy, and Healing Touch, and has additional
studies in holistic and integrative healthcare from the Union training in the areas of mindfulness, stress management, mental
Institute in Cincinnati, Ohio. Dr. Jackson is a school nurse in health, and addictions. She was honored to receive the American
Philadelphia, nurse consultant for Chester County Department of Holistic Nurses Association Holistic Nurse of the Year award in
Children, Youth and Families, and Professor Emerita at Eastern 2011.
University in St. David’s, Pennsylvania, where she was holistic Christina Jackson has disclosed that she has no significant
curriculum coordinator for the undergraduate and graduate financial or other conflicts of interest pertaining to this
nursing programs. She practices, teaches, and uses many course.
integrative healing strategies for self-care and clinical patient
Content Reviewer: Mary C. Ross, RN, PhD, is an experienced
care. She has been teaching mindfulness practices continually for
nursing educator with extensive clinical experience in multiple
the past 3 decades in various academic and fitness settings. Dr.
areas of nursing including mental health. She is a retired Air
Jackson is an award-winning author in the field of holistic nursing
Force flight nurse and previous chair of a national Veterans
and served as the associate editor of the journal Holistic Nursing
Administration Advisory Council. She has extensive experience
Practice: The Science of Health and Healing, for which she still
in nursing and has numerous publications.
serves on the editorial board. She has published many articles
and book chapters pertaining to mindfulness practices for health, Mary Ross has disclosed that she has no significant financial
stress reduction, trauma, and addiction, and has frequently or other conflicts of interest pertaining to this course.
Course overview
Mindfulness is an innate ability that can be developed with increase positivity, safety, and pleasure in work. Through
practice. Cultivating mindfulness skills has been shown to benefit completing this course, healthcare professionals (HCPs) will
mental and physical health including managing chronic illnesses, expand their understanding of what mindfulness is in its many
pain, addiction, anxiety, and depression. Using mindfulness forms. These include formal, structured approaches as various
to reduce personal reactivity in order to choose constructive approaches to meditation, as well as informal, beneficial daily
ways to respond can improve communication, interpersonal habits of thinking and behavior. Learners will explore the
relationships, and responses to conflict and trauma in personal evidence base for the uses and benefits of mindfulness, and
and work settings. Building mindfulness-based, stress-reduction learn ways to immediately apply these practices to daily personal
principles and techniques into healthcare environments can and professional life.
Learning objectives
Upon completion of the course, the learner should be able to do Discuss formal and informal approaches to mindfulness.
the following: Choose mindfulness strategies for self-care and patient-
Discuss mindfulness in terms of psychophysiological education that enhance mood, cognition, resiliency, and
health, self-regulation, and well-being. Analyze evidence- coping with stress. Examine ways to apply mindfulness to
based benefits and appropriate application of mindfulness enhance communication, safe practice, and management of
practices. stress and conflict in healthcare environments.
Explore mindfulness origins and techniques.
● Complete the self-assessment quiz questions either ○ An affirmation that you have completed the
integrated throughout or all at the end of the course. educational activity.
○ These questions are NOT GRADED. The correct answer ○ A mandatory test (a passing score of 70 percent is
is shown after you answer the question. The questions required). Test questions link content to learning
are included to help affirm what you have learned from objectives as a method to enhance individualized
the course. learning and material retention.
○ The correct answer is shown after the question is ● If requested, provide required personal information and
answered. If the incorrect anser is selected, a rationale payment information.
for the correct answer is provided. ● Complete the MANDATORY Course Evaluation.
CE Broker reporting
Activity director
Disclosures
course activity.
Disclaimer
Course verification
INTRODUCTION
The word mindfulness may conjure an image of a formal seated training applied to HCPs and their work environments indicates
meditation practice; however, this is only one of many ways improvements in communication, compassion, interpersonal skills,
to build the innate state of noticing and being in the present and amplified safety, job satisfaction, and leadership skills as a
moment without judgment (Kabat-Zinn, 2013). This intentional result of applying mindfulness (Benzo et al., 2017; Braganza et al.,
awareness is a universally inherent ability and skill that can be 2018; Braun et al., 2019; Burton et al., 2016; Ireland et al., 2017;
cultivated and, like a muscle, developed and strengthened Lamothe et al., 2016). These meta-analyses of mindfulness training
through the regular use of simple exercises. These strategies for HCPs also demonstrate significant reductions in anxiety,
may be structured such as body scan, progressive muscle burnout, depression, and distress, along with improvements
relaxation (PMR), and various types of meditation practices, or in compassion, well-being, and enhanced mindfulness ability.
be informal such as breathing and mindful eating exercises. This Also growing are the number of studies demonstrating effective
awareness can be a state achieved through training or can be a application of mindfulness training embedded in HCP student
longstanding personality trait. It can be developed no matter preparatory programs, laying the foundation for mindful practice
what spiritual, cultural, or religious beliefs one holds, and it can (Correa de Araujo et al., 2020; Greene et al., 2019; Gutman et al.,
be measured using various self-report questionnaires. This way of 2020; Spinelli et al., 2019).
being can be contrasted with mindlessness, which occurs when Healthcare environments have always been complex, and this
thoughts are scattered and one is distracted by competing stimuli, has only increased over the last year with the demands and
rumination about the past, and worries or plans pertaining to the stressors placed on HCPs because of COVID-19, changes in
future (Black, 2011). workplace processes, constant reprioritization, patterns of
Robust research demonstrates the benefits of increased morbidity and mortality, and restrictions secondary to pandemic
mindfulness for physical and mental health issues including pain, mitigation strategies. Regular mindfulness practice may reduce
asthma, cancer, tinnitus, coping with cancer, anxiety, depression, stress and enhance coping and resilience in HCPs.
trauma, and addictions (Atia & Sallam, 2020; Blanck et al., 2018).
A rapidly expanding body of evidence focused on mindfulness
AWARENESS IN THE HERE AND NOW: MINDFULNESS DEFINED
Mindfulness is an ancient concept and its practice and benefits (Serrone et al., 2018). It also sets the stage for self-regulation
have been described in many Eastern writings pertaining to yoga and responsiveness to “what is” as life unfolds rather than
practice, Buddhist philosophy of non-attachment, and traditional reactivity, inaccurate assumptions, or investment in what “is not”
Chinese medicine. In the late 1970s, Jon Kabat-Zinn, a biologist that leads to unmet expectations, needless drama, and stress
and professor at the University of Massachusetts Medical School, with its physiologic sequelae. Developing greater nonreactive
became very interested in the mind-body benefits of mindfulness self-awareness then leads to a “mindfulness-mediated stress
practices especially as applied to people with significant health response” and adaptive coping responses that actually
challenges. He has been credited with bringing mindfulness to change the brain and nervous system through the process of
the West, defining mindfulness as “paying attention in a particular neuroplasticity (Seaward, 2022).
way: on purpose, in the present moment, and nonjudgmentally” Psychologist Ellen Langer, referred to as the “mother of
(Kabat-Zinn, 1994, p.4). This awareness happens in each moment mindfulness” in the West, has observed that most of us are not
and is cultivated by setting a purposeful intention to notice things fully present much of the time and we miss both opportunities
that typically go unnoticed and doing so in an accepting way and threats in our lives. These threats could be physical, such
to increase ability to relax and experience healing, and develop as not being fully present while driving our car, or relational,
self-control and wisdom (Kabat-Zinn, 2013). If we use all of our such as not noticing something important about a loved
senses when we walk, we hear our foot falls and feel our arms one. Langer states that being present is facilitated by simply
swinging; when we eat, we see, smell, and taste our food and noticing new things and waking up to the reality of the present
notice our level of hunger; when we drive, we focus on the road moment. She has linked mindfulness to reversing effects of
and environment. This focused, attentive way of being is soothing aging and increased longevity in her creative research with older
to the nervous system and changes our physiology over time. participants who lived for a week in an environment retrofitted to
Through the 1980s and 1990s, physicians referred over 18,000 20 years earlier and who conversed as if they were living in that
patients to Kabat-Zinn’s 8-week structured Mindfulness-Based time period. By altering their reality and focus, the experimental
Stress Reduction (MBSR) program to learn mindfulness skills. group experienced significant improvements in hearing, vision,
Because this all happened at UMass, a research setting, his work and youthful appearance. This demonstrates the power of
inspired many randomized, controlled studies that demonstrated mind-body connection and neuroplasticity that can be fueled by
benefits for people experiencing heart disease, cancer, chronic present moment-oriented states of awareness (Powell, 2018).
pain, fibromyalgia, type 1 diabetes, irritable bowel syndrome, Extensive research on elite level athletes demonstrates an ability
anxiety, depression, asthma, psoriasis, headache, and multiple to be in the here and now. Being able to quickly “shake off”
sclerosis (Kabat-Zinn, 2013). the last play or point and not lose focus worrying about what
Mindfulness causes a positive shift in perspective often referred might happen in the next play allows present moment awareness
to as “reperceiving” that allows one to view daily experiences that fuels excellent performance. Tennis players who were able
more objectively, allowing for more control and choice in terms to erase focus on the last point – whether they won or lost it –
of the way one responds to these experiences (Kriakous et al., achieved notably slowed respiratory and heart rate by the time
2021). This shift, often called “decentering,” happens because of they walked back to the baseline of the court. Many athletes
the decision to pay attention in new ways without any judgment have a phrase or word they repeat to themselves to assist in this
or evaluation. Simply developing a routine of noticing positive process, such as “shake it off” (also known as a mantra). There are
and negative responses to situations, thoughts, and feelings, many great athletes and researchers speculate that this quality of
and saying to ourselves in the moment “maybe this is a good mindfulness and ability to quickly self-regulate to present-moment
thing, maybe not, we’ll see” cultivates a habit of nonjudgment. awareness is part of what makes an athlete elite rather than just
This tone can shift a negative attitude to greater positivity excellent (Ungerleider, 1996).
FOCUS ON BREATHING
Awareness of the breath is a part of most formal and informal Movement practices (e.g., yoga; qigong), use the breath as
approaches to mindfulness training. Although our “monkey a way to connect to and focus on awareness in the present
mind” can wander and jump from thought to thought like moment.
monkeys in the trees, our body is always in the present moment. Another useful technique is the Square Breath which involves
We cannot survive for more than a few minutes without oxygen, inhaling and holding, then exhaling and holding. If you think of
so our breath literally links us to life. Using our breath to calm inhaling fully for four counts and holding for two counts, then
our mind and body is a foundational tool for mindfulness. exhaling more slowly for six to eight counts and holding again
Full abdominal breathing or belly breathing emphasizes a full for two counts, you might picture more of a trapezoid than a
inhalation (allowing the diaphragm to drop down) to the count square, but give it a try and notice how you feel! Simply paying
of four followed by a slow exhalation to the count of eight, which attention to breathing completely brings more oxygen to our
triggers the parasympathetic nervous system and “rest and cells, thus reducing low-grade alarm in the nervous system body
digest” response. Shallow breathing is often rapid with equal scan that can exist as a baseline when we are not breathing fully.
inhale and exhale phases, and this can trigger the sympathetic Being relieved of this subtle yet potent underlying state of alarm
fight or flight response. There is a bidirectional phenomenon is soothing and frees us physiologically to think more clearly
with breathing meaning that when frightened, anxious, or in and be more calm and less distracted in the present moment
pain, breathing is faster and shallower. Intentionally slowing and (Seaward, 2022).
deepening the breath and doubling the exhalation phase creates
calmness and reduces pain. Likewise, purposefully speeding up Breathing is probably the most powerful tool we have to cope
breathing will create feelings of discomfort and anxiety. Try this adaptively with our daily stresses. It can literally change our
and experience the power of breath control. physiology and is always ready to implement for our benefit.
Remembering to use our breath is a big step on the path of
When we breathe fully, we maximize the exchange of oxygen mindfulness. See the Resources for apps and videos at the end
and carbon dioxide, bathing cells in more oxygen, stimulating of this course that can train breathing to enhance mindfulness,
the lymphatic system, and balancing the autonomic nervous relaxation, cognitive performance, and healing.
system to promote parasympathetic dominance and restorative
processes. Many mindfulness training strategies, such as
progressive muscle relaxation (PMR), Meditation and Mindful
AWARENESS OF THE BODY
Since our body is always in the here and now, using various abdominal muscles through the center of your body toward your
strategies that make use of the body can amplify mindfulness spine. Allow your shoulders to drop down away from your ears.
training. Using a technique referred to as a body scan is Hold and then release your contracted muscles as you release
one approach to mindfulness. A body scan is done from your breath slowly. Repeat and notice how you feel. This is an
a comfortable seated or supine position. After using full effective way to quickly reduce stress in the moment.
abdominal breathing to become calm and focused, the scan Mindful walking (aka walking meditation) can be done even in a
begins by bringing awareness to either the toes (then moving small space. This involves paying attention with all of your senses
up) or the top of the head (then moving down), noting any as you walk – what does it feel like to put one foot in front of
sensations such as heaviness, warmth, coolness, tingling, or the other and move through space, maintaining balance? What
discomfort. If pain is perceived, one can shift positioning and do you see, hear, smell, and feel? Place your feet with intention,
consciously direct breath to that part of the body with a clear notice the involvement of your upper body in your gait and the
intention to relieve the discomfort. If you begin with top of the movements of your arms. What sensations do you experience?
head, then awareness is next brought to the eyes and forehead Are your shoulders pulled up or relaxed down away from your
with the same process, and then to the jaw, throat and tongue ears, as they should be? Notice the sounds of your feet and your
area, and down the body to the toes. A body scan can be done breathing as you move and try to maintain focus on this activity
in 5 minutes or slowly conducted over 30 minutes or more (see alone. Mindful walking provides refreshment and a mental re-set
Resources for links). With repetition, anyone can build this skill and is easy to incorporate frequently as you go about your work.
to achieve increasing levels of present moment awareness and
comfort.
A body scan combined with the tensing and releasing of various
muscle groups moving down the body is known as PMR and A body scan includes which one of the following?
is very useful for reducing anxiety and tension (see Resources a. Starting at the head.
for links to PMR scripts and videos). To quickly experience
b. Alternating tensing then relaxing muscles.
whole body relaxation, simply allow your body weight to rest
c. Using the breath.
comfortably on your chair, grab each side of the seat with your
hands (the right hand grips the right side, left hand left side) d. Starting at the feet.
and pull yourself down onto the seat as you try to press your
feet into the floor. Breathe in through your nose as you pull your
INFORMAL APPROACHES TO MINDFULNESS

Aside from breathing and awareness of your body, there are and can positively impact one’s relationship with food and the
many ways to cultivate mindfulness anywhere and anytime. choices one makes. Simply using your nondominant hand to
Simple strategies can be started immediately and do not require eat will slow you down, forcing you to be more aware of what
setting aside time, but rather can be embedded into activities you are doing, and ensuring that you don’t eat mindlessly. Eat
of daily living. Use relaxation breathing. Savor simple pleasures. slowly enough that you allow your internal appetite feedback
Pay more attention to the world and people around you using loops to register satisfaction. Often, we override these self-
all of your senses, living in the moment with intentional focus, regulatory mechanisms and eat more than we need or want.
and avoid judging the thoughts and feelings you experience. Look at and smell your food, enjoy eating with all of your senses.
Just notice and accept them with greater objectivity and Take small bites, put your utensil down between each bite and
nonevaluative detachment, then let them go. chew thoroughly, noting the texture and flavor of your food.
Try driving mindfully: be without music, news, and your phone. Digestion begins in the mouth with salivary amylase, so allow
How does it feel to sit in the seat? Listen to the road noises and this natural process to unfold and experience nourishment. Take
any other sounds around you. Whether dark, bright, rainy, or time to notice when you are no longer hungry and stop eating
dry, notice the things you see around you. Pay attention to what when you do (Fung et al., 2016). Mindless, distracted eating
bubbles up in your thoughts, any associated emotions, and any such as while working, driving, or watching TV and other screens
sensations in your body. Accept whatever comes with interest is associated with anxiety, eating too much, and weight gain.
and curiosity, avoid any judgments. Don’t self-criticize for any However, socializing with friends and family while appreciating
reason (including being self-critical!), and if you do, just notice the food and how it came to be at the table can enhance
this, and then release it. Keep bringing yourself back to present nourishment. Studies show that mindfulness can be helpful when
moment awareness of driving – no ruminations about the future addressing binge and emotional eating because it addresses
or past – if they begin, get back to focusing on what you can shame and guilt that may be associated with these behaviors
see, hear, feel, touch, or taste in the here and now. Once you through increased awareness in the moment and emphasis on
arrive, pay attention, and notice how you are. How do you feel – nonjudgment and is a helpful addition for those with eating
what is your mood? How would you describe your thinking? This disorders (Stanszus et al., 2019).
simple exercise is refreshing and can make a profound difference Engaging in these types of informal behaviors as often as
in mood and readiness for concentration. possible and for as long as possible can significantly improve
Eating mindfully can transform the experience of taking in attention, problem- solving, awareness during stressful
food. This means using all five senses along with awareness of situations, mood, and sleep (Mayo Clinic Staff, 2018). With
thoughts and feelings about the food you eat. To feel gratitude regular daily practice, the more automatic these behaviors
for what we take in, and to think about the people who grew or will become, and the more benefits will be derived. It is also
tended and prepared the food and the potential health benefits more likely these behaviors will become personal habits to be
makes eating a different experience. Nonjudgmental awareness employed during stressful situations. There are many free apps
of fears or concerns about food and the body is important to help you with daily mindfulness (see Resources).
Case study
Pat works in a busy in-patient rehabilitation setting where a supervisory position in the near future. Rather than merely
everything has become more intense and difficult because surviving during this difficult time, Pat wants to thrive and
of COVID protocols. Masks make interactions more difficult. is looking for more creative coping strategies. Hearing a lot
Visitation hours have changed drastically, and patients are about benefits of Mindfulness-Based Interventions (MBIs)
more anxious without their support systems present. Staff for stress management, Pat looks at the online resources
cannot always carve out time to offer emotional support. Pat available through the Universities of Pennsylvania, Minnesota,
is not enjoying the work in the same way but is still aiming for and Massachusetts, which have extensive, free materials (see
Resources). Excited about the wealth of resources, Pat reads With work beepers, feasible plans for coverage can be designed
articles, completes free-learning modules, and watches videos so everyone reaps benefits of being officially unavailable during
to learn how to do relaxation breathing, body scanning, PMR, breaks/meals. Setting boundaries regarding how we use our
and mindful eating. Pat downloads two free apps to support personal phones also supports mindfulness. For example,
mindful practices: Calm and Bhuddify. during a work break, instead of spending the whole time
Pat has learned to approach tooth brushing, hand-washing, with your phone, give yourself just 5 minutes to catch up on
and driving as opportunities to build mindfulness. Using a brief anything significant and then turn it off. Text and social media
form of journaling involving writing down thoughts and feelings alerts, and even vibration, act as distractors from present
in the moment in order to help identify and release them has moment awareness. Being thoughtful about our personal phone
been very beneficial. This practice had given great relief by communications during a break (which may serve as a distractor
helping to get negativity “up and out,” providing a quieter mind by directing thinking into past or future concerns) may provide
and calmer body. The more Pat practices these skills, the more true respite to refresh our thoughts and emotions in positive
enjoyable work has become. Pat feels increased energy, sense of ways, enhancing our ability to focus on the work at hand.
humor, and levels of compassion. Pat’s external environment has Unplugging from overwhelming stimuli gives the nervous system
not changed, but Pat’s internal environment has shifted toward and cognitive processes a chance to rest and reboot, reducing
greater resiliency through intentionally practicing mindfulness. stress levels. Using most of break time to mindfully enjoy food
or go outdoors for a quick, full-sensory walk in the fresh air
Question: Pat learned that mindful use of technology and taking promotes present moment awareness and refreshes the body-
breaks from technology are important, but how can this be done mind. Consider keeping that phone off while working for safety
in a busy healthcare setting? reasons, as well. Research demonstrates that when attention
Discussion: As HCPs, we rely on technology and electronic is captured by a distractor (such as a vibrating phone), focus is
medical records to facilitate communication and documentation; disrupted to the degree that people are three times more likely
however, the ways we approach this can be controlled. Wise use to make an error in perception or judgment (Chen et al., 2019).
of technology provides opportunities to practice mindfulness.
To ensure that technology doesn’t get in the way of your Self-Assessment Quiz Question #2
interactions with patients and colleagues, avoid placing the
computer or device between you and them. Instead, keep it Which statement is most true about mindfulness practices?
off to the side, giving full attention to listen with care, and then a. Mindfulness practices must include meditation to make
turn to document. Patients feel more understood, cared for, and significant differences in health.
safe when they have been listened to with eye contact and full b. Mindfulness practices can be simple things done regularly
attention (a form of “beginner’s mind”), and this builds trust and
and have a dose-related effect.
promotes safety as attentive clinicians are more likely to pick up
on changes and early warning signs. Take a minute to attend to c. One can overdo mindfulness activities and become
the patient’s environment. Notice the room temperature, odors, lethargic or overly stimulated.
cleanliness, and how the patient is lying or sitting. d. Mindfulness is a fad and will pass as all fads do.
FORMAL (STRUCTURED) APPROACHES TO MINDFULNESS

Formal practices imply that time is being set aside to focus on many other structured approaches to developing mindfulness
building mindfulness skills. Body scans and mindful walking are skills.
quite simple yet are considered formal practices, and there are
Mantra
An easy way to begin experiencing a meditative state is to practice include saying to oneself “relax” with each out breath,
repeat a single word or brief phrase as a focus to quiet the mind. or “I breathe in peace” with an in-breath, and “I breathe out
Called mantra, this practice is one of the simplest and easiest worry” with exhalation.
forms of meditation, and unlike seated meditation, can be a safe
strategy even for those whose mental health is vulnerable (e.g., Box 1: Practice Mantra Meditation
recent psychotic episode, recent substance recovery, significant
depression.) To experience mantra, repeat a word, sound, prayer, Choose your focus word or phrase and sit in a comfortable
phrase, or muscular activity (e.g., manipulating beads with position.
thumb and fingers as with rosary) along with breathing (see Box Set an intention to calm your body-mind-spirit.
1). It is helpful to choose calming, positive words and phrases Close your eyes and breathe fully, expanding into your
firmly grounded in your belief system (e.g., “have mercy on me”; abdominal area using a “4 in, 8 out” count. Relax your muscles
love; peace; relax; One; “the Lord is my shepherd”; “hail, Mary, using a body scan or Progressive Muscle Relaxation (PMR).
full of grace”; Shalom; Insha’Allah; Om Shanti; or “there is every
reason to be hopeful”). Because it is less intense and requires Breathe slowly and repeat your mantra.
less effort in terms of focused attention, it can be applied readily If other thoughts/feelings come to mind, take notice, say,
to derive benefits. Other examples of mantra practice include “that’s interesting,” “whatever,” or “I’ll see you later,” and
saying to oneself “relax” with each out breath, or “I breathe return to present- moment awareness focused on your breath
in peace” with an in- breath, and “I breathe out worry” with and mantra.
exhalation. grounded in your belief system (e.g., “have mercy Continue for as long as suits you, and then open your eyes.
on me”; love; peace; relax; One; “the Lord is my shepherd”; Notice how you feel.
“hail, Mary, full of grace”; Shalom; Insha’Allah; Om Shanti; or
“there is every reason to be hopeful”). Because it is less intense
and requires less effort in terms of focused attention, it can be
applied readily to derive benefits. Other examples of mantra
Labyrinth walking
Walking a labyrinth is another accessible meditative activity that is only one way in and one way out. Labyrinths can be found
builds on mindful walking, becoming a deeply contemplative outdoors and indoors in places of worship, academic settings,
experience. Labyrinths are ancient and were found throughout hospitals, and rehabilitation and retreat centers. Portable
Europe, often along routes to the Holy Land traveled by spiritual labyrinths painted on large pieces of canvas are available to be
Pilgrims (http://www.cathedrale-chartres.org/en/,245.html). rolled out. A labyrinth is a walking path, not a maze, and allows
There are many versions of labyrinths involving differing patterns, the walker to move slowly on a path through a typically circle-like
perhaps representing the spiritual journey, but with all there design toward the center and then back out again.
To gain mindful benefits using a labyrinth, use your breath to
calm and focus yourself before entering the labyrinth. You might
ponder a particular question as you prepare to enter on the path
or ask for a solution to a problem that’s been bothering you. Walk
the labyrinth slowly in a balanced and reflective manner focusing
on the journey, not the destination. Use your senses – feel the air,
listen to your feet on the path, detect any fragrances, take in what
you see. Look down and around you and keep your breathing
full, deep, and regular. Enter and wind your way through to the
center, pausing there to reflect, pray, sing, or just breathe. Exit by Note: From Labyrinth (https://www.dreamstime.com/royalty-free-
the same path and allow any concerns to slip away as you focus stock-images-labyrinth-image12531639 ).
on the here and now. Many labyrinth users like to journal thoughts
and feelings afterwards (see Resources to locate a labyrinth and
find information on using a walking labyrinth for health).
To have a scaled-down labyrinth experience, finger labyrinth
images such as this one are easily accessed online. Using a
finger or non-ink end of a pen to slowly trace a path through to
the center and back out of this image with awareness of your
breath and intention can bring mindful relaxation.
Formal meditation
The term meditation describes mental activities that “train Since the focus of this course is mindfulness, inclusive styles
the self-regulation of attention and awareness with the goal of meditation will be described; however, some strategies
of enhancing voluntary control of mental processes, thereby commonly used to assist meditators using exclusive styles can
increasing well-being” (Lomas et al., 2019, p. 1193). There also assist those practicing inclusive styles of meditation to refine
are many styles of meditation, and though there are moving present-moment attention. These strategies include “mental
meditation practices as already described, formal meditation is repetition,” accomplished by using a mantra as described above
usually taught as sitting with legs crossed in a lotus or modified to assist with relaxation; “repeated sounds” such as ocean
lotus position with eyes closed. There are two subtypes of formal waves, rainfall, drums, chimes, bells, and meditation music;
meditation: Exclusive (or restrictive) and Inclusive (or opening- “physical repetition” such as awareness of breathing which
up). Exclusive meditation involves concentration and focus on involves focus on the rise and fall of the chest and abdomen,
one thought or inner experience, excluding all other distractions running, swimming, or knitting; and “tactile repetition” such
and sensations in order to quiet the mind. Transcendental as holding or manipulating a small object like a stone or bead
Meditation and the Relaxation Response are popular examples (Seaward, 2022).
of exclusive meditation styles. The goals of exclusive and
inclusive meditation styles are different. Rather than pushing Self-Assessment Quiz Question #3
away present-moment thoughts and feelings and viewing them
as intrusive (as with exclusive styles), inclusive meditation invites Which of the following is not true about formal meditation?
mindful awareness of thoughts and feelings that are noticed a. Restrictive styles may view thoughts and feelings as
and accepted. This inner exploration of feelings and thoughts
intrusive
is welcomed and accepted without judgment as a way to gain
insight, and then allowed to recede with a return to present b. Inclusive styles may be more helpful in developing
moment awareness of thoughts, sensation, and emotion. So mindfulness skills.
being with all of the things that arise is part of mindfulness and c. A person who fishes and ties flies may experience tactile
facilitates greater peace with all aspects of self in keeping with repetition and a moving meditative state.
nonjudgment, a hallmark of mindfulness practices, thus leading d. A person walking a labyrinth is engaging in an informal,
to growth and change. nonstructured meditative experience.
Lovingkindness meditation
Cultivating self-compassion and self-kindness fosters a sense of relaxation. Set intention to broaden compassion toward yourself
our common humanity and compassion for others, essential for and others, and repeat these phrases as you breathe fully:
HCPs (Fredrickson et al., 2017). Mindfulness can train this quality “May I be peaceful; may I be happy; may I be safe; may I be
as it emphasizes nonjudgment toward one’s experiences and well; may I be free.” Then think of someone you love or are
responses, including enhanced ability to soothe and comfort concerned about and offer again: “May you be peaceful; may
oneself when facing stressors (Raab, 2014). Lovingkindness you be happy; may you be safe; may you be well; may you be
meditation has been found to be particularly helpful in free.” Next, think of someone with whom you are struggling or
developing self-compassion and positively impacts clinical care in conflict, and offer the same expressions. Finally, think of all
(Gracia-Gracia & Olivan-Blasquez, 2017). In a study looking at people and the world around you and offer these words with
HCP staff, patients, and caregivers who attended a one-day compassion and hope: “May all be peaceful; may all be happy;
mindfulness training, it was found they were still using mindful may all be safe; may all be well; may all be free” (Anselmo &
compassion in their home and work life 3 years later to reduce Yasui, 2022, p. 285). Evoking positive emotion is powerful –
anxiety and pain, improve sleep and feelings of empowerment, notice how you feel after doing this meditation. Lovingkindness
create calmness and relaxation, and to focus and cope more meditation is particularly helpful when counteracting burnout
adaptively with stress (Lowson, 2020). in HCPs because self-compassion stimulates the flow of
Lovingkindness meditation is an ancient practice evident additional positive emotion, which counteracts feelings of anger,
throughout Buddhist teachings brought to Western awareness frustration, and disengagement (Leiter & Maslach, 2016).
through the writings of teachers like Thich Nhat Hanh. This
version, adapted for helping professionals, can be done in a
seated position, after calming oneself with breath and muscle
MINDFULNESS-BASED STRESS REDUCTION (MBSR)
Developed by Dr. Jon Kabat-Zinn in the late 1970s, MBSR is a
structured 8-week program that teaches various daily practices Box 2: Healthcare Professional Consideration: MBSR
that build mindful awareness and skills, including relaxation Structure
breathing, body scan, gentle yoga, seated meditation, loving Traditional MBSR courses address these topics, which are often
kindness meditation, and walking meditation, preferably offered in a variety of time formats:
outdoors. Because of its sound research base originating at the Simple awareness; mindful eating exercise; learning to do
University of Massachusetts, MBSR continues to be frequently a body scan.
used as the intervention for mindfulness in research studies. Attention and the brain; introduction to seated
Though sometimes it is used in its original 8-week format, some meditation. Dealing with thoughts; introduction to gentle
researchers and programs may compress or abbreviate the yoga practice. Stress: responding vs. reacting; breathing
course so the total number of hours of content varies widely, exercises.
with some courses offered over fewer sessions and with varying
Dealing with difficult emotions and physical pain.
amounts of homework practice time expected between sessions.
Still, most meta-analyses of the research support the efficacy of a Mindfulness and communication; lake and mountain
variety of program structures, although it seems the benefits can meditations. Mindfulness and compassion;
be dose-related, i.e., those participants with more time to take Lovingkindness meditation.
in and practice the concepts will develop the skills more quickly Developing one’s own practice.
and strongly (Burton et al., 20-60 minutes of daily homework between sessions through
2016; Hilton et al., 2019; Kriakous et al., 2021; Lamothe et reading, audio/video tapes, gentle yoga, informal mindfulness
al., 2016; Lomas et al., 2019; Spinelli, 2019). MBSR programs practices such as eating and seated mindful meditation.
have been shown to be effective when delivered in fully online
or hybrid formats combining telecommunication and in- Self-Assessment Quiz Question #4
person strategies. In a low-cost and feasible hybrid program
that delivered MBSR training to nurses in a corporate setting, You notice that when angry, you become upset about being
participants experienced reduced stress and burnout, and angry which amplifies your distress. This is an example of:
improved general health. Improvements were still accruing 4
months after completing the program, and those who continued a. Observing your thoughts.
to practice MBSR continued to experience benefits, while those b. Describing your thoughts.
who didn’t practice did not (Bazarko et al., 2013). c. Reacting to your inner experience.
d. Understanding your feelings.
Instruments used to specifically measure mindfulness outcomes
in studies include the Five Facets of Mindfulness Questionnaire Kabat-Zinn describes seven attitudes that set the foundation
(FFMQ), the Kentucky Inventory of Mindfulness Skills, the for mindful meditation practice: “nonjudgment” means you
Toronto Mindfulness Scale, and the Mindful Awareness and are an impartial witness to your experience; “patience” is
Attention Scale (see Resources for links to measure your own possible when we accept that growth happens in its own time;
tendency toward mindfulness). The FFMQ is frequently used “beginner’s mind” happens when we strive to see everything
in research on HCPs and assesses the following domains of as if for the first time; “trust” in yourself, your experiences,
mindfulness (Greene et al., 2019): and your feelings; “non-striving” is important as there is no
● The ability to observe internal and external experiences such goal except to just be; “acceptance” means we see things as
as thoughts, feelings, sensations, sights, sounds, smells, and they are in the present moment; and finally, “letting go” of the
environmental conditions. impulse to grasp or push away experiences (Kabat-Zinn, 2013).
● The ability to describe in words these internal and external “MBSR has become the gold standard for applying mindfulness
environmental observations. to the stresses of everyday life, and for researching whether
● The ability to act with awareness rather than behaving mindfulness practices can improve mental and physical health”
mechanically or mindlessly, meaning to be fully engaged and (Mindful Staff, 2021).
present to activities in the moment.
● Being nonevaluative about one’s own thoughts and feelings, Healthcare Professional Consideration: Relieving Suffering
which is referred to as nonjudging of inner experience. Over the years, graduates of Kabat-Zinn’s MBSR teacher-
● The tendency to not allow thoughts and feelings to be training programs have helped millions of people to
upsetting but rather to let them come and then pass, which is experience more emotional and physical well-being and
referred to as nonreactivity to inner experience. reduce physical distress, including those in mental or physical
pain. Many have had dire health challenges and prognoses.
Negative well-being outcomes frequently measured in Helping people “learn to dance” with their health challenges
mindfulness research for HCPs include anxiety, burnout, changes lives. The following equation illustrates this: Pain +
depression, distress, and perceived stress. Positive outcomes Resistance = Suffering.
frequently measured in the mindfulness research on HCPs
include compassion (especially self- compassion), empathy, The overall goal is to reduce suffering. There are times when
positive well-being, professional quality of life, resilience, and the source of physical or emotional pain cannot be identified
mindfulness itself. For the most part, research shows significant or changed. But sources of resistance such as fear, traumatic
benefits across these outcomes for HCPs training in mindfulness or troubling memories, avoidance, stress, automatic negative
(Kriakous et al., 2021; Lomas et al., 2019). thoughts, and reactive attitudes can always be addressed.
Mindfulness, with its emphasis on nonjudgement and
It is noteworthy that when effects are tested months and years detachment, targets this part of the equation. If resistance is
after completion of studies to see how long benefits last, it lessened, overall suffering is reduced, even if pain remains the
has been found that some skills that were not demonstrated same (Kabat-Zinn, 2013).
as strongly at the end of the study become stronger as time
passes after the mindfulness training interventions. Researchers
speculate that it may be easier to develop the skills of
observation and description, for example, but it takes time and
practice to become proficient at other skills like nonjudging and
nonreactivity to inner experience (Kriakous et al., 2021; Lomas
et al., 2019). See Box 2, MBSR Structure for traditional MBSR
training course structure and the links.
The Five Facets of Mindfulness Questionnaire (FFMQ) is often
used in MBSR and general mindfulness research. This tool is
designed to:
a. Look at the ability to demonstrate patience and the
beginner’s mind.
b. Measure tendencies toward acceptance and objectivity.
c. Assess ability to observe and describe inner experiences
without judging or reacting to them.
d. Demonstrate creativity in exerting present moment
awareness.
MINDFUL MOVEMENT PRACTICES
Americans are embracing mindful movement practices sometimes offered at the end of practice during this time, or as
such as yoga, T’ai chi, Qigong, and Pilates at increasingly a stand-alone class. Research demonstrates that Yoga Nidra is
significant rates. Meta- analyses as to effects of these practices effective in reducing psychological and physiological effects of
demonstrate that mindful movement practices are very effective anxiety and depression (Ferreira-Vorkapic et al., 2018).
in reducing anxiety and depression, and improving quality of Mindfulness-based yoga (MBY) is an approach that weaves
life and sleep (Schuver & Lewis, 2016; Weber et al., 2020; Yan mindfulness concepts throughout the practice to amplify
So, 2020). These practices use flowing movements, rhythmic the benefits. There can be some level of mental or physical
sequences, or held postures all linked with conscious breathing discomfort when practicing mindful movement. Being able to
patterns. They all emphasize the balance and flow of energy recognize this and allowing it to arise and then pass through and
throughout the body and a reflective, non-competitive, self- resolve is an important aspect of learning in mindful movement
accepting awareness to feel energized yet calm in body-mind practices. In a study looking at youth with concussion symptoms
and spirit. T’ai chi is considered a slow martial art and, as with persisting for > 4 weeks, an 8-week MBY intervention offered
all martial arts, focus on the breathing and lines of energy is once a week resulted in increased self-efficacy over social,
essential. Qigong is a potent health promotion and healing emotional, and academic domains (Paniccia et al., 2019). An
intervention based in traditional Chinese medicine that requires example of connecting mindfulness to yoga practice would
attention to sequences of movement coordinated with breath be using the breath to ground practice. Noticing sensations,
and attention to the flow of energy throughout the body. This both comfortable and uncomfortable, and allowing them to just
requires a great deal of focus to empower the practice, and be, rather than resisting them, and not judging or reacting to
one can gain tremendous physical strength along with stress discomfort, whether physical or emotional, enhances the benefits
reduction through regular practice. Pilates is focused on flow of mindful yoga. Being able to observe and describe them is
of movement, careful transitions, alignment, and core strength. part of the learning with mindful movement. It is not unusual for
Awareness of the muscle groups working at any given time and people to experience emotional releases during yoga practice, as
connecting to the breath amplifies the effectiveness of practice, the body holds cellular and muscular memory. Moving the body
so Pilates builds present-focused awareness. These practices facilitates release of deeply held and unprocessed emotion. It is
build mindfulness because of the deep body-mind awareness not uncommon to experience emotional release and cry during
accessed through the practice, being fully in the here and now savasana.
through focus on breathing and movement, and reflection
through periods of stillness. People often find these mindful Healthcare Professional Consideration: Experiencing
movement practices on their own and a majority don’t tell their Present Moment Awareness Through Movement
healthcare practitioners about them. Benefits derived include Warrior II is a powerful standing pose in yoga, with torso upright
chronic and acute pain relief and improvements in mood (Wang over hips that are centered between the feet while in a wide
et al., 2019). lunging stance. Beginning practitioners often lean forward
The ancient practice of yoga has long been used to calm the or backward in this pose rather than maintaining upright and
body so that inner peace and awareness can be accessed. centered alignment. It is useful to think of staying in the present
Meaning “union or to yoke,” yoga practice cultivates mind- (remaining centered) rather than fretting about past (leaning
body-spirit connection. An essential feature of yoga practice backward) or worrying about future (leaning forward). In this way,
is a focus on breathing. Mindful breathing directly affects being in the present moment is embodied.
the nervous system, triggering parasympathetic, restorative There are many types of yoga from vigorous flow styles with
processes. Most yoga practitioners would say that without aerobic impact to slower paced, such as Iyengar where poses are
the focus on breathing, there is no yoga. Yoga is a heavily held with alignment as priority, to restorative styles like Yin that
researched modality with robust evidence supporting benefits emphasize deep stretching and cultivate the parasympathetic
to both physical and mental health. Kiecolt-Glaser (2010) found response. Mindful movement practices are easily accessed
that yoga creates a positive endocrine-immune response that through fitness and community centers and online. Because they
reduces stress. There is usually time taken at the end of yoga are gentle and can be modified to seated practice, they are often
practice to lie in corpse pose (savasana). Because the physical offered to seniors; however, the power of these practices to build
practice and breathwork have released tension and brought core and overall strength, balance, flexibility, and mental grit
greater levels of peace and calming, the body-mind can deeply cannot be underestimated. Anyone can find a suitable style of
synthesize the benefits of the practice during savasana. Guided mindful movement (Cramer et al., 2016; see Resources for links).
yoga meditation or Yoga Nidra for relaxation and healing is
STRUCTURED MINDFULNESS PROGRAMS FOR MENTAL HEALTH
MINDFULNESS-BASED COGNITIVE THERAPY (MBCT)
It has been well-established over 40 years of research through stress, and be more open to self and others (Schure
that mindfulness-based interventions (MBIs) benefit those et al., 2018). Over the years, MBSR has been adapted and
experiencing anxiety and depression. Regular MBSR programs tailored to target individuals with mental health concerns. In the
have been shown to benefit those with significant mental health late 1990s, Jon Kabat-Zinn began working with colleagues to
concerns, including Post-Traumatic Stress Disorder in veterans combine aspects of MBSR with the cognitive behavioral model,
who reported learning how to relax, deal better with the past and Mindfulness-Based Cognitive Therapy (MBCT) was born.
while staying in the present, accept adversity and breathe Research supports benefits of MBCT for individuals with a wide
variety of mental health concerns as it reduced depression in because of memory, learning, and related physiologic changes,
adult participants across a meta-analysis of studies that used wiring the body-mind in such a way that reinforces more of that
the Beck Depression Inventory or the Hamilton Depression negative state. By learning to calm the body- mind with mindful
Rating Scale as outcome measures (Thimm & Johnsen, 2020). strategies and insert positive thoughts into a negative mood
MBCT was found to be more beneficial for children with anxiety state, the negative mood can be disarmed.
than group therapy that included standard cognitive behavioral The movement aspects of MBCT (mindful breathing, yoga,
principles (Shetty et al., 2020); reduced anxiety and depressive body scan meditation, walking meditation) use the body to
symptoms in older adults (Hazlett-Stevens et al., 2019); treated help increase awareness of what is happening in the mind.
Generalized Anxiety Disorder (GAD) across a systematic review The cognitive aspects help people to explore the relationship
and meta-meta-analysis of trials using randomized designs between thoughts and feelings, question the veracity and
(Ghahari et al., 2020); was feasible and acceptable to individuals usefulness of these thoughts and feelings (e.g., Is this true? Am
with cardiovascular disorders who experienced depression I over-reacting? Is there a pattern to my thoughts and feelings?
(Alsubaie et al., 2018); and reduced distress and symptoms Is it helpful?), identify themes, and address patterns that are
associated with tinnitus better than relaxation therapies in not helpful. Understanding their symptoms more deeply is also
several studies (Husain, 2020). In a review and meta-analysis of a goal with MBCT, as this can foster acceptance, detachment,
49 studies looking at the use of MBCT or MBSR for non-clinical efficacy, and self-compassion.
samples (i.e., those with milder mental health symptoms), it
was found to reduce rumination, worry, stress and distress, and Once thoughts and feelings are identified from a position
increase well-being when compared with passive control group of greater calmness and objectivity, one can choose how to
effects (Querstret et al., 2020). Beneficial effects seem to last respond, including substituting more constructive thoughts
over time as measured by several of the studies reviewed. and grounding behaviors such as breathing, affirmations, and
empowering mantras. Examples of self-talk to counteract the
Like MBSR, MBCT is usually formatted as an 8-week program ANTS that awfulize, generalize, personalize, minimize, label or
with 2-hour sessions each week during which mindful and catastrophize include the following:
cognitive behavior strategies are taught and practiced, and ● “I’m doing the best I can” rather than “I always screw things
about 45 minutes of daily homework on the days between up.”
sessions involving reading, journaling, listening to audio ● “What do I need/want?” rather than “I never get what I
recordings, practicing mindfulness breath work, movement, need/want.”
meditations, and more. The goal is to teach participants a ● “What skills do I need to cope better?” rather than “I’m a
new, more resilient way of being with distressing thoughts mess.”
and symptoms, and to shift awareness of these thoughts and ● “Do I need to temper my emotions before I act?” rather than
symptoms in the direction of acceptance, reframing, and release “This is awful and I need a drink.”
when possible. Working with automatic negative thoughts (ANTs) ● “Am I avoiding the best solution because it would be
is one component, and learning to recognize and question them challenging/difficult for me?” rather than “I’m so tired of
from a perspective of calmness, thus detaching from negative trying and getting pushed back down again, things will never
emotional impact, is part of the therapeutic shift in perspective. get better.”
For example, negative mood can become self-perpetuating
DIALECTICAL BEHAVIORAL THERAPY
Resiliency is the ability to bounce back after finding ourselves become more aware, and then to describe them in detail in order
down. Mindfulness-enhanced therapies can increase that quality to develop understanding and self-control. DBT emphasizes that
of resilience by interrupting negative thought patterns that do thoughts and feelings are not facts and may not accurately depict
not help us and replacing them with positive self-talk and self- reality. This leads to the skill of participating in the moment with
care activities. But for people with particularly difficult mental presence. The constructive focus becomes not worrying so much
health challenges, making changes can seem daunting if not about what is right or fair, but rather looking toward ultimate
impossible. Dialectical Behavioral Therapy (DBT) is a therapeutic goals. Through relationship with the therapist, group interaction,
approach that was initially developed in the 1980s to address and practicing DBT skills, access to the “Wise Mind” we all
self-harming behaviors among women, many of whom were possess enables clients to make decisions using emotion and
thought to have Borderline Personality Disorder. Since then, the reason combined. Learning ways to appropriately assert wishes
technique has been developed and adapted to address adults and stay calm in the face of reactions from others is a core skill
and adolescents suffering with suicidality, chronic emotional that promotes acceptance and change that go hand in hand in
dysregulation, substance use, disordered eating, anxiety and DBT (see the link to the CeDAR Addiction Treatment Center found
mood disorders, and disruptive behavioral disorders (Singer et in Resources to learn more about application of DBT).
al., 2017). While this approach includes weekly individual and
group therapy sessions, a major component of DBT is to train Self-Assessment Quiz Question #6
participants in core mindfulness skills. Self-regulation of powerful
emotions is essential when dealing with these diagnoses, and MBCT may be appropriate for you, if:
mindfulness facilitates the perspective needed to respond in a. You are suicidal.
safer ways and choose healthier coping strategies.
b. You’d like to deal with ANTs and anxiety.
DBT skills include allowing oneself to experience feelings fully c. You are seeking sobriety.
without judgment, maintaining a problem-solving orientation, and d. You’ve been diagnosed with Borderline Personality
focusing on future outcomes rather than reacting in the moment. Disorder.
The first skill is to observe thoughts, feelings, and behaviors to
THE PHYSIOLOGY OF MINDFULNESS AND STRESS
Our brain works to process and respond to stress by two major response becomes distressing and creates interpersonal and
pathways – a bottom-up, more primitive amygdala-driven health issues as new stressors inappropriately trigger the same
process characterized in the extreme by hypervigilance and trauma response. The cascade of neurohormones released
reactivity; and a top-down, more positively adaptive process when reacting via the amygdala supports a fight or flight
via the prefrontal cortex (PFC) characterized by calm reason. physiology and also releases pro-inflammatory substances that
Through neuroplasticity, frequent use of one response will create systemic and neuroinflammation, damaging tissues in
stimulate growth in that path and pruning in the other. For many organs over time. Conversely, learning to practice self-
example, those with a history of trauma are often amygdala- awareness and focusing on the present moment allows for
driven, and while this response may have served as a survival a PFC- driven response that actually grows these structures.
mechanism, with the original threat no longer present, this When practiced daily, the mediating effects of mindfulness
and enhanced coping calm bottom-up reactivity and promote Evidence-based practice! HeartMath Resiliency Training for
a more parasympathetically-dominated, top-down response, HCPs. A quasi-experimental study of 29 HCPs in an academic
thus impacting these physiologic and inflammatory issues in the medical center who were given an 8-hour HeartMath training
direction of resiliency and healing (Baim et al., 2022). course demonstrated improvements in stress management and
The HeartMath organization conducts research on physiologic resiliency. Course content included physiology, heart-centered
effects of evoking positive emotion. As with Lovingkindness breathing, intention and positive emotion techniques, and
meditation, evoking positive emotion using the HeartMath opportunities to validate training through use of biofeedback
Quick Coherence Technique has been found to amplify benefits instruments. Before and after data showed improvements in
of mindfulness. There is neural tissue in the heart, and research employee health, well-being, and performance. Qualitative
demonstrates that neural signals originating in the heart exert interviews described ways participants were also applying
effects on brain structures that impact emotional self-regulation. HeartMath techniques with patients for management of pain,
Through bioelectromagnetic and neurochemical pathways, insomnia, and anxiety (Buchanan & Reilly, 2019).
these connections can favor sympathetic or parasympathetic
dominance. Evoking positive emotion using the heart-brain
connection stimulates the growth hormone, DHEA, and restorative Healthcare Professional Consideration: HeartMath Quick
parasympathetic processes. Shifting psychologically to positive Coherence Technique This brief exercise has profound
emotion creates physiologic and cognitive shifts that enhance psychophysiological effects on heart rate variability, mood, and
health and performance (https://www.heartmath.org/research/; stress-coping: Prepare with breathing and muscle relaxation.
see Evidence-Based Practice and Healthcare Professional Once relaxed, place a hand over your heart and imagine
Consideration boxes below. ; see Resources for links). breathing warmth and light into the area, feeling it expand.
Imagine an instance where you’ve felt strong positive emotion
such as love, gratitude, peacefulness, or joy. It could be
picturing a loved one present or passed on, a pet, a sleeping
child, or an activity. Allow yourself to deeply feel this positive
emotion, letting it fill your heart (https://www.heartmath.com/
quick-coherence-technique/).
APPLYING MINDFULNESS ACROSS HCP ROLES AND SETTINGS

Mindfulness applied to HCP self-care
The work of HCPs often happens in emotionally and physically stairwells are good places to get away to collect yourself and
intense environments, and requires head, heart, and hands. practice mindful stretching.
Rates of burnout are rising because of the complexity of Expand your awareness by expanding your senses. To do this
healthcare environments, caring for an aging population, visually, take time to relax your gaze to widen your peripheral
increased use of technology, and economic pressures view. Do this with hearing by pausing to notice sounds you hear
compounded by recent pandemic shutdowns. HCPs are in the distance. Notice how you feel after doing these expansive
surrounded by intense stimuli such as phones, monitors, techniques. Take time to look at something you think is beautiful
alarms, ever-changing patient status, endless questions from several times throughout your waking hours. It could be looking
patients/families and colleagues, high stakes accountability and at a painting, out a window at trees or sky, or at a photo or stone
responsibility, ethical demands, caregiver burden secondary to you carry.
vicarious trauma, and the need to make meaningful connections
under these stressful conditions. We cannot pour from an empty Before an important interaction, take time to pause, breathe, and
cup, so self-care should be a priority for HCPs. Like brushing, center by pulling your thoughts and feelings into the here and now
flossing, and exercise, mindfulness is an essential self-care habit to eliminate distractions. When meeting people, notice something
for promoting health and well-being that a person must do for about them such as their posture, facial expression, or eye color.
themselves. In a study of hospital- based nurses, the practice Take a deep breath and settle into being fully present to that
of personal mindfulness was strongly associated with a health- interaction. People notice when we give the gift of attention, and
promoting lifestyle and job satisfaction (Lee et al., 2019). it significantly enhances our effectiveness in work and personal
relationships. Touch the door jamb before you enter a room,
A good place to begin mindfulness practices is with accessible pause to breathe and set a positive intention (e.g., “My goal for
strategies described earlier such as breathing, body scan, this conversation is a win-win outcome”; “I want to be a healing
mindful eating, driving, and mantra. Sampling the apps, presence for this person”).
videos, and websites provided are easy ways to cultivate and
support mindfulness. Interventions need not be lengthy to be It is helpful to complete a self-assessment to understand
effective, and can be embedded into the work day and even which areas of self-care (physical, relational, spiritual, mental,
during meetings. A brief group learning MBI involving focused nutritional, stress management) may be in need of attention.
breathing offered for 30 minutes during two respiratory therapy The Bakken Center at University of MN (see Resources) has
staff meetings with measures of distress post-intervention self-assessments that will point in the direction to address first.
yielded reduced physical and emotional stress and increased Observation and awareness of one’s own early stress warning
sense of calm (Luzarraga et al., 2019). signs is another way to trigger mindfulness practice for personal
health and well-being. Try noticing over the next few days:
When arriving at the computer or accessing the EMR, take a few ● Where in your body do you first feel stress – jaw tightness,
breaths, smile, and say, “I am ready” or “I can do this” with each stomach pain/change in bowel habits, rapid breathing,
exhalation to calm and center. Feel your posture, feet on the dizziness, memory loss, confusion/difficulty concentrating,
ground, or your hips on the seat. During work, use hand hygiene joint pain, muscle tension, fatigue, headache, heart
as an opportunity to breathe and set a healing intention. Feel palpitations, or chest pain?
the soap and the water or smell the gel and feel coolness and ● What behavioral signs of stress do you experience – nail-
sensations as you rub your hands together, creating a moment biting, sleep problems, use of substances such as alcohol,
of hand self-massage. Lobby for pleasant hand hygiene products drugs, marijuana or nicotine, over/under-eating, isolation,
in the workplace that are kind to your skin. Use mindful walking fidgeting, jumpiness, procrastination, difficulty making
in the hallways and take steps instead of elevators. If you feel decisions, excessive talking, or interrupting others?
yourself becoming upset at work or notice any early warning ● What negative emotional states are triggered with or
stress signs, take a moment to pause, breathe, and perhaps brought on by stress – anxiety, anger, loneliness, depression,
change your venue. Bathrooms, day rooms, chapels, and sadness, helplessness, hopelessness, frustration, jealousy, or
insecurity?
Quicker recognition of personal stress states provides insight from mindful self-care in terms of reduced stress and urgency,
and motivates an increase in strategic self-care behaviors. When increased feelings of control, ease and energy, better handling of
combined with exercise (especially mindfully moving with breath strong emotion and vicarious trauma, greater acceptance of that
awareness), nutrition (and mindful eating practices), and time which is beyond one’s control, and improved job performance
spent in nature (such as a mindful walk in the woods), mindfulness (www.ihi.org: PFC 103: Incorporating Mindfulness into Clinical
creates greater physiologic adaptation and coping. HCPs benefit Practice).
Case study
Chris works in an emergency department that has been athletes, police officers, healthcare professionals, students,
intermittently overwhelmed during the COVID pandemic. and folks with various illnesses, it is understandable that folks
The demands to communicate under adverse conditions, come at the practice with expectations of instant, life-changing
multi-task, and shift priorities have been exhausting, and the results or doubting the effectiveness. Actually, having these
level of anxiety among colleagues and patients has been expectations runs counter to the core philosophy of mindfulness,
unprecedented. There is also the burden of feeling sad and which is to observe reality as it is, rather than the way we’d like
helpless in the face of obvious suffering, and Chris has been it to be! And, though many techniques are simple, they are skills
contemplating changing jobs for self-protection as well as to that improve with practice, and it may take time to change habits
protect loved ones. Chris has become more reactive lately of mind and particularly reactivity, which can be a stubborn
with angry outbursts and a shorter fuse, has more low back pattern. New habits must be practiced consistently over time
pain than ever before, and is drinking alcohol more regularly as they are a new way of viewing and being in the world.
to “take the edge off” daily life. Chris’s spouse has suggested Frustration and setbacks can be met with patience, acceptance,
counseling, but concerns regarding cost and time as well as not and persistence. So, while many people do notice immediate
wanting to do telehealth sessions has prevented follow-through. improvements, Chris shouldn’t give up easily. Building a support
A colleague suggests Chris complete a free 8-week online system could help Chris, such as finding a buddy to join in
Mindfulness-Based Stress Reduction (MBSR) course because the mindfulness journey. Sharing experiences and discussing
of the strong evidence base for reducing feelings of anxiety challenges and ideas along the way can motivate completion
and depression (see Resources for link). After the first week, of the training, skills practice, and application of learning over
Chris still feels anxious and has problems sleeping, and decides time. Setting aside 10-minute blocks of time with a partner to do
mindfulness just isn’t working because “it’s too difficult finding body scan, progressive muscle relaxation, mindful meditation,
the time and energy to tame this restless mind.” or walking can be powerful. Research supports the likelihood
Question: It’s possible to sabotage a mindfulness practice with that completing the 8-week MBSR program and sticking with
unrealistic expectations and doubts. What would you suggest to the daily practices until they become routine will help Chris
Chris? cope more adaptively, experience improvements in back pain,
reduce reactivity, and perhaps embrace next steps for healing, as
Discussion: With all of the solid research findings and hype needed.
about mindfulness and how it benefits corporate executives,
Mindfulness applied to patient care
The mindful HCP will see the person behind the patient and HCPs can teach calming breath, brief body scan, and muscle
will have a presence that is felt by others. There are times when relaxation in the moment to help patients through stressful or
mindful attention is particularly important, such as during times emotionally difficult times. Using all of the senses to enhance
of transition and “hand-offs” when safety can be compromised self-control and present-focus is helpful: asking yourself or your
because of breaks in focus that may lead to errors. Procedural patient to identify four things they see; three things they hear;
time-outs have become routine, especially in operating rooms two things they feel; and one thing they taste can stunt panic
before surgeries to ensure correct patient, correct procedure, attacks through grounding in the here and now (www.ihi.org:
and correct side. Taking this time to breathe and affirm these PFC 103: Incorporating Mindfulness into Clinical Practice).
essential “rights” is a mindfulness exercise. Create healing environments for your patients that honor
Evidence-based practice! Reducing Errors Through mindfulness by reducing unnecessary distractions and noise,
Mindfulness. A quantitative, quasi-experimental study of nurses placing beautiful pictures or, when possible, orienting beds
(Ekkens & Gordon, 2021) measured the effectiveness of STOP toward windows to provide a view of something interesting.
mindfulness training (Stop and Think Of the Patient) in reducing Encourage mindfulness when moving out of bed for ambulation
medication errors, emphasizing “Self-acceptance of becoming and toileting to enhance awareness of balance and safety.
present in the moment, Teaching mind-mapping to work with Meta-review research by occupational therapists looked at
distractions ..., Opening the mind to ... redirect thinking to deal connecting mindfulness to occupational participation and
with strong emotion and difficult experiences ..., Practicing supported the value of embedding mindfulness through breath
meditation ...” (p. 5). Mindfulness thinking reduced the rate of and focus strategies into daily routines. In so doing, support for
medication errors and should be taught as part of orientation attention to actions, sense of flow, and goal-directedness were
and continuing education (p. 7). strengthened (White et al., 2020).
Mindfulness applied to leadership

It is beneficial for leaders to develop a personal practice of honor the personhood of HCP staff facilitates the processing
mindfulness in order to enhance their own self-awareness, of emotion and loss in positive ways that promote resilience.
self-regulatory skills, clear thinking, collaborative skills, and So, incorporating group pauses after the loss of a patient can
compassion for self and those they lead (Walsh, 2020). Curiosity be as important as pauses before procedures, and builds social
and beginner’s mind facilitate hearing all sides of a problem support and teamwork (Bartels, 2014; Cain, 2021).
or situation to create effective solutions. Using breathing The Institute for Mindful Leadership offers many useful resources
techniques and body scan will ground leaders as they engage to help leaders develop their skills as leaders using mindfulness
in complicated interactions. Leaders can help their staff by and self- awareness. In “The 6 Simple Mindfulness Steps to Make
embedding brief programs and trainings into staff meetings and Meetings More Useful,” Institute Director Janice Marturano
providing on-the-job opportunities for continuing education (2020) recommends the following: send the topic(s) out ahead
in MBIs (Gauthier et al., 2015; Lin et al., 2019; Muir & Keim- of time inviting people to bring their ideas; ask that laptops
Malpass, 2020; Penque, 2019). Providing an atmosphere that and phones be put away unless essential; begin the meeting
welcomes mindfulness at work is important and could affect with quiet time so folks can center themselves; give everyone
staffing patterns and load practices around breaks, mealtimes, 2 minutes initially to share their ideas uninterrupted, instructing
and use of technology. Providing places and times to pause and all to listen without judgment; with 10 minutes remaining, ask
everyone to pause and share what they’ve heard and invite final Healthcare Professional Consideration: Circle Process
questions or ideas; end with a summary of decisions and any Circle process and using a talking stick or object can enhance
next steps. Circle process can facilitate mindful listening. communication in groups, especially if the dynamic is heated.
Simply agreeing that the one holding the stick (or object)
gets to talk, and the act of waiting, as it is passed along,
can provide calmness and space for breath, and encourage
listening and thoughtful response rather than reactivity (for
more information, go to https://www.csh.umn.edu/sites/csh.
umn.edu /files/csh-restorative-dialogue-circle-process.pdf).
Case study 3
Randy runs an interdisciplinary health clinic within a hospital Discussion: Staff identify a meta-review (Hilton et al., 2019) that
and is concerned that staff are becoming burned out. describes the benefits HCPs derived from workplace mindfulness
Communication has been less organized, rates of errors meditation, including reduced pain, substance use, depression,
are increasing, and nerves are frayed. Randy has learned somatization, anxiety, and improved sleep and psychological
of extensive mindfulness programming provided by the well-being. Excited and empowered, they want to embed time
Institute for Healthcare Improvement (IHI), and decides that for 10-minute mindfulness meditation into everyone’s schedule
the “well-being of healthcare professionals” and “improving and are planning staff coverage. They also learn that some
safety metrics” are paramount. The free online programs for healthcare settings have spaces dedicated to staff self-care with
healthcare professionals include open access modular courses healthy snacks, essential oils, relaxation and mindfulness audio
on Mindfulness (see Resources for links), so Randy schedules and videotapes, and chair massage offered on a regular basis.
time during work for staff to complete the modules and brown They decide to contact the staff who drove these projects to
bag discussions to share ideas. The response is positive and learn about the process, funding, and sustainability. Lastly, they
several staff have volunteered to form a “mindfulness team” to discover robust data on using mindfulness for those with cancer
keep the momentum going. diagnoses (Cillessen et al., 2019; Compernolle & Sledge, 2020;
Question: What next steps could staff take to embed Lee et al., 2017) and reducing opioid dosage (Garland et al.,
mindfulness into their work environment? 2020). They plan to pilot mindfulness programs in the Oncology
and Pain Clinics.
CONSIDERATIONS WHEN USING AND RECOMMENDING
MINDFULNESS-BASED INTERVENTIONS (MBIS)
While most mindfulness practices are noninvasive and relatively trauma. Trauma- informed mindfulness practices can be helpful
safe, difficult emotions can arise during some forms of relaxation and resources are available for this purpose (Gallegos et al., 2020;
and meditative practices where people may let down their Gilgoff et al., 2019; Petrucelli, 2019; Treleaven, 2018); however,
guard and move to deep places within the psyche. While this proceeding with caution is advised. If you have a patient who
insight is usually helpful to increase awareness and expands our experiences an adverse response to relaxation, breathwork, or
choices in terms of responding to these feelings that become meditation practices, you can stay present and therapeutic by
conscious, they may be frightening to some. Said another remaining grounded yourself – feel yourself solidly standing or
way, with awareness and support we can heal what we feel, sitting, breathe fully and slowly exhale, speak calmly, and coach
but, depending on our circumstances, these feelings can be your patient to breathe fully and to feel the support of their chair
disturbing and there are times when a certain strategy may be or bed, and to use all of their senses to see, hear, feel, smell, and
too invasive. For example, if someone has PTSD, has just finished be present to the here and now. They can tense and then relax
a rehab program for addictions, or had a significant loss and is muscles groups (a simplified PMR) to self-soothe. Remind them
experiencing acute grief, certain types of meditation may allow that this discomfort will pass. While it may be grounding and
uncomfortable feelings to become too intense. Or, if someone soothing to some folks to put your hand on their arm, make sure
has a history of dissociative episodes, psychotic breaks associated that this touch would be welcomed. Some folks experiencing a
with schizophrenia or bipolarity, untreated anxiety or depression, high level of agitation may reject touch.
or unhealed traumatic experiences, deep relaxation or structured
meditation may be too much. In cases such as these, simple Self-Assessment Quiz Question #7
breath awareness training and mantra repetition: “I am calm”;
“I am safe”; “I breathe in peace, I breathe out worry”; or “I am You have a client who you know has a history of early trauma
stronger every day” can provide the perfect level of calming and and recent treatment for addictions. You see that the standard
centering without triggering instability. Or, a mindful walking or treatments are not fully addressing her suffering, and decide to
moving meditation such as a gentle yoga practice might be best. do which one of the following?
Beginning mindfulness experiences with a partner or therapist a. Ask her if she is open to developing skills that could help
may be the best option for those with a mental health issue or
her relax and feel calmer.
disturbing history.
b. Ask her how she feels about breathing exercises.
Many of our patients have had trauma secondary to adverse c. Tell her that when she is feeling better, she should consider
childhood events (ACEs), domestic violence, military service, developing a meditation practice.
being a first responder or police officer, and may carry a burden d. Recommend she begin a brief, not-too-intense seated
of undiagnosed/undisclosed physical, psychological, or vicarious meditation practice.
EVALUATING THE EVIDENCE BASE FOR MINDFULNESS-BASED INTERVENTIONS
Evidence-based practice is derived from three sources, each expertise to implement an array of appropriate healing strategies
having equal importance: evidence derived from research can more accurately meet patient needs.
studies; the expertise and judgment of the healthcare There is a strong and broad evidence base for MBIs, and
professional; and patient values and preferences (Mackey & much of this research is randomized and controlled, though
Bassendowski, 2017). An integrative perspective leads HCPs methodologic issues have been cited because of small sample
to use the most complete evidence available to provide less size, inability to double-blind, not using more active control
invasive therapies first, moving toward more invasive only conditions to strengthen the ability for comparison, treatment
as required. Dr. Abraham Maslow said, “If your only tool is fidelity (ensuring interventions were delivered as planned),
a hammer, every problem looks like a nail,” so having the interpreting self-report measures, variability in interventions with
revisions of standard mindfulness protocols, longer follow-up
assessment, and reporting of instructor training as an indicator directed, not requiring a professional, and, if acceptable to the
of quality (Davidson & Kaszniak, 2015). A recent systematic client, HCPs can apply and recommend them as appropriate.
review of randomized, controlled mindfulness studies from
2000 to 2016 found improvements were needed in several Self-Assessment Quiz Question #8
of these areas, including larger sample sizes and treatment
fidelity (Goldberg et al., 2017). Still, with interventions such as Since MBIs carry very little risk, it is best to:
mindfulness, randomized control studies are less practical to a. Use and recommend them frequently in case they might
conduct and often less appropriate, so considering application help.
of findings should be done through a careful evaluation of each b. Use and recommend them cautiously since patients may
study. not feel comfortable with them.
MBIs have been shown to be inexpensive, noninvasive, c. Use and recommend them as appropriate, following
accessible, and effective across a broad range of physical, considerations for client safety.
mental, and behavioral health issues. They are mostly self- d. Only use them with a clear evidence-based rationale.
Conclusion
While we enjoy anticipating the future and learn from evidence-based strategies practiced for just minutes a day,
reflecting on the past, striving each day to be more fully along withinformal attitudes of mindfulness embedded into
present in the moment supports improved health, greater daily activities, creates a powerful web of psychophysiological
contentment, and purpose. Mindfulness is an innate skill support. Tapping into readilyavailable resources, HCPs can
that can be strengthened through practice to boost personal find many ways to improve personal and workplace well-
resilience and professional effectiveness. A variety of being using MBIs.
Resources
Tools to Measure Your Own Tendency Toward Mindfulness as a State Embedding Mindfulness Into Our Healthcare Workplaces From S.
or a Trait Braganza – Berkeley. https://greatergood.berkeley.edu/images/uploads/
Philadelphia Mindfulness Scale: https://greatergood.berkeley.edu / oneED_Business_Case.pdf
quizzes/take_quiz/mindfulness Harvard Nutrition Source for Mindful Eating
11 most popular mindfulness assessment tools: https:// https://www.hsph.harvard.edu/nutritionsource/mindful-eating/
positivepsychology.com/mindfulness-questionnaires-scales-assessments- Interview With Jon Kabat-Zinn (2021) https://www.mindful.org/major-
awareness/ turning-point-mindfulness-health-care/
Apps to Experience and Cultivate Mindfulness Any Time, Most Institute for Mindful Leadership https://instituteformindfulleadership.org/
Include Breath Coaching, Guided Imagery, Body Scans,Progressive common-mindfulness-questions/
Muscle Relaxation, Tones, and Relaxation Music
Buddhify: Beautifully designed to bring more calmness, clarity, and peace iRest Yoga Nidra https://www.irest.org/
through meditation and mindfulness. Mindfulness Matters. National Institutes of Health https://
Calm: Breathing programs, guided meditation, stories to support sleep, newsinhealth.nih.gov/2012/01/mindfulness-matters
and more to enhance focus and reduce anxiety. Has a free leveland Mindfulness programs including an 8-week MBSR course and a
subscription (for purchase) level of programs. Mindfulness at Work course; free online learning modules; free
Grow Mindfulness for Teens: Aimed at adolescents. communityMindfulness Mondays online gathering; research reports and
other resources such as breathing, body scan, and muscle relaxation
Headspace: Free and for-purchase mindfulness and meditation audios programs. Free mindful movement and meditation classes can be found
helpful for mind-body health, sleep, personal growth, and manyaspects at https://www.csh.umn.edu/community-classes-and- events/stress-
of life. busters-free-stress-reduction-classes-students-faculty-and-staff
Insight Timer: Free app with mindfulness activities, meditations, and Open School free online courses PFC 103: Incorporating Mindfulness
programs to enhance sleep, mood, and promote happiness. into Clinical Practice; theNeed for Mindfulness in Healthcare, Finding
MindBell: A Tibetan bowl bell tone throughout the day reminds you to and Creating Joy in Work; and WIHI Mindfulness and Patient Safety
pause, breathe, and notice your inner and outer environment. programs; many additional multimedia, interdisciplinary resources and
ReSound Tinnitus Relief: For relieving and managing tinnitus, this research on mindfulness.http://www.ihi.org/education/IHIOpenSchool/
app offers a combination of sound therapy, relaxing exercises, resources/Pages/PFC-103-Incorporating-Mindfulness-into-Clinical-
meditation, and guidance. Practice.aspx file:///C:/Users/Owner/Downloads/IHIWhitePaper_
FrameworkForImprovingJoyInWork.pdf
Smiling Mind: Free mindfulness meditation programs and activities
developed by psychologists and educators. For adults, adolescents,and Palouse Mindfulness Center
children, aimed at bringing awareness and balance to all aspects of life Free 8-week MBSR course; extensive resources; community and group
including eating, hugging, walking, and more. mindfulness and meditation activities; lectures and more.https://
palousemindfulness.com/covid19/index.html
From Linette & Bryant (2017). Managing stress in health care with
meditation: Got a minute? (One-Moment Meditation [OMM] free app): Penn Medicine Mindfulness Programs at University of Pennsylvania https://
https://www.americannursetoday.com/managing-stress-health-care- www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-
meditation/ service/mindfulness
Programs to Learn, Practice, and Apply Mindfulness Qigong Video: 30-Minute “8 Pieces Brocade”
Bakken Center for Spirituality and Healing at the University of Minnesota Practice vimeo taught by HCP Laura Chalfant, Certified Rolfer and Body
Schools of Medicine and Nursing Talk therapist and founder of the Energy Freedom Circle
https://vimeo.com/507615182/ee0733389c
Benson-Henry Institute for Mind-Body Medicine – Mass General in
Boston, MA www.massgeneral.org/bhi The Institute for Healthcare Improvement (IHI): www.ihi.org
http://www.ihi.org/communities/blogs/10-mindfulness-exercises-for-the-
CDC-Kaiser Adverse Childhood Experiences (ACE) Scale health-care-workplace
These questionnaires address Family Health History as well as The Purposeful Pause and Body Scan Techniques
Health Appraisal and have male and female versions. Brief ACE self- http://www.ihi.org/education/IHIOpenSchool/resources/Pages/PFC-103-
assessments are also available on this site. Calculating your score can Incorporating-Mindfulness-into-Clinical-Practice.aspx
help aim self-care.
The University of Minnesota’s Extensive Range of Mindfulness Programs
https://www.cdc.gov/violenceprevention/aces/about.html and Resources
CeDAR Addiction Treatment Center https://www.csh.umn.edu/events/mindfulness-programs
Colorado Center uses many mindfulness strategies to help with recovery. University of Massachusetts Center for Mindfulness in Medicine, Health
https://www.cedarcolorado.org/articles/mindfulness/ Care and Societyand the Stress Reduction Clinic (founded by Dr. Jon
Kabat-Zinn) https://www.umassmemorialhealthcare.org/umass-memorial-
center-mindfulness
Yoga Nidra Resources fr=mcafee&ei=UTF- 8&p=Elmo+belly+breathing+Youtube&type=E21
https://health.clevelandclinic.org/what-is-yoga-nidra/ 0US105G0#id=1&vid=13c90c7bcbf0b45c5e73df25813c67ec&action=
HeartMath Resources click
HeartMath https://www.heartmath.org/ Upaya Zen Center in Santa Fe, New Mexico www.upaya.org
For a free introductory experience aimed at the difficult times we’ve Find a labyrinth near you https://labyrinthlocator.com/
been going through pertaining to COVID From the Labyrinth Society in Trumansburg, NY
https://experience.heartmath.com/?u=16 www.labyrinthsociety.org
To understand more about the science of heart rate variability and Read about the ways to use labyrinth walking
applying HeartMath to patient care and self-care https://www.binghamton.edu/bhealthy/labyrinth.html
https://www.heartmath.com/health-professionals/?utm_
source=bing&utm_medium= cpc&utm_campaign=branding&utm_ https://www.webmd.com/balance/features/labyrinths-for-modern-
content=heartmath&network=o&utm_term=heartmath&msclkid=27690 stresses
c1e0090142f89336c506a91d15c https://www.peacelabyrinth.org/how-to-walk-the-labyrinth
To explore HeartMath research https://www.heartmath.org/research/ https://www.veriditas.org/New-to-the-Labyrinth
For an Intro to Quick Coherence Technique Combining Heartmath Videos
Mindfulness With Positive EmotionA 2-minute audio MP3 for download Dr. Rick Hanson – Calm Strength for Healthcare Providers
https://www.heartmath.org/resources/heartmath-tools/quick-coherence- https://www.youtube.com/watch?v=Rgt4mjDtffg
technique-for-adults/
Dr. Eckhart Tolle – Start 2021 Doing One Thing at a Time
A 2-minute video of Quick Coherence technique https://www.youtube.com/watch?v=z04JLGnFO48
https://video.search.yahoo.com/search/video?fr=mcafee&ei=UTF-
8&p=Heart+Math+Quick+Coherence+Technique&type=E210US105G0 Dr. Lynn Rossy – 20-Minute MBSR Yoga Practice
#id=1&vid=8932d339e017f1aaddc1174ec09ed022&action=click https://www.youtube.com/watch?v=rWfsThgLBCs&list=PLbiVpU59JkVa
FMGi0A8Im_hfSh-SWsFwg&index=6
A 4-minute version of Quick Coherence technique https://video.search.
yahoo.com/search/video?fr=mcafee&ei=UTF- 8&p=Heart+Math+Quick Palouse Mindfulness 13-Minute MBSR Lovingkindness Meditation
+Coherence+Technique&type=E210US105G0#id=1&vid=8932d339e0 https://www.youtube.com/watch?v=v1HdSkAJsRc&list=PLbiVpU59JkVa
17f1aaddc1174ec09ed022&action=click FMGi0A8Im_hfSh-SWsFwg&index=11
Labyrinth Resources Ten Mindful Movements from Plum Village and Thich Nhat Hahn
AACN Well-Being Initiative https://www.youtube.com/watch?v=BzA6Hu840to&list=PLbiVpU59JkVa
https://www.aacn.org/ nursing-excellence/well-being-initiative FMGi0A8Im_hfSh-SWsFwg&index=7
AACN’s Healthy Work Environment Half-hour seated meditation with a focus on the breath from Palouse
https://www.aacn.org/nursing-excellence/healthy-work-environments Mindfulness
https://www.youtube.com/watch?v=XRhqFWio3U0&list=PLbiVpU59JkV
American Meditation Institute in Averill Park, NY aFMGi0A8Im_hfSh-SWsFwg&index=3
www.americanmeditation.org
Dave Potter leading a Raisin Eating mindfulness exercise based on Dr.
Healthy Nurse Healthy Nation. Channeling Mindfulness in Nursing Jon Kabat-Zinn’s MBSR program
https://engage.healthynursehealthynation.org/blogs/8/677 https://www.youtube.com/watch?v=_CZEEYMXr8Q&list=PLbiVpU59JkV
Sesame Street’s Elmo With Common and Colbie Caillet Video About aFMGi0A8Im_hfSh-SWsFwg&index=1
Belly Breathing https://video.search.yahoo.com/search/video?
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mindfulness-exercises/art-20046356 interventions involving meditative movementson quality of life, depressive symptoms,
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based stress reduction and mindfulness-based cognitive therapy for psychological
MINDFULNESS FOR HEALTHCARE PROFESSIONALS

1. The correct answer is C. 5. The correct answer is C.
Rationale: Breath is essential; however, one can start at the Rationale: Patience and beginner’s mind are attitudes that help
head or the feet and it is PMR that uses muscle contraction and set the tone for mindful meditative practice. While acceptance,
relaxation. objectivity, nonjudgment, and awareness are all aspects of
2. The correct answer is B. mindfulness, the FFMQ measures tendencies of observation
Rationale: Mindfulness has been around for centuries, the and description of inner experiences without judging or
research agenda and opportunities for application continue reacting to them.
to grow, and one can develop significant mindfulness muscles 6. The correct answer is B.
without formal meditation practices, achieving greater effects Rationale: MBCT is appropriate for anxiety; however, DBT is
with more frequent practice of mindful behaviors. more appropriate for conditions with more extreme emotional
3. The correct answer is D. features.
Rationale: Restrictive (exclusive) styles view thoughts and 7. The correct answer is A.
feelings as pulling the meditator away from focus, and inclusive Rationale: It is always helpful to ask the client what they
styles open the meditator to whatever is happening in the are ready and willing to do. She may not know how to
moment, including thoughts and feelings. For many, fishing respond about breathing exercises if she has never done any.
and tying flies are certainly tactile and physical ways of moving Recommending seated meditation is not yet appropriate as it
into meditative states of focused awareness and self-regulation. may trigger distressing thoughts and feelings, and telling her
Although accessible, noninvasive, and easily done, labyrinth is about a future meditation practice is not helpful, as she needs
viewed as a more structured, formal approach to mindfulness. something in this moment to help reduce her suffering.
4. The correct answer is C. 8. The correct answer is C.
Rationale: These are feelings, not thoughts, and you are Rationale: MBIs can be used as appropriate when the HCP
aware of a negative reaction to them which you may not yet believes they will be helpful to a particular client. The evidence
understand. base for mindfulness is so broad that application for most any
condition is bound to have been looked at for effectiveness.
However, since the risks are so low, MBIs are worth trying or
adding into standard treatments to reduce stress and increase
well-being.
Course Code: ANCCNC03MF22

Staying Healthy: Vaccine Preventable Diseases
10 Contact Hours
Release Date: July 7, 2021 Expiration Date: July 7, 2024
Faculty
Author: Adrianne Avillion, DEd, RN, is an accomplished continuing education for healthcare professionals and consulting
nursing professional development specialist and healthcare services in nursing professional development.
author. She earned a doctoral degree in adult education, an Adrianne Avillion has disclosed that she has no significant
MS in nursing from Penn State University, and a BSN from financial or other conflicts of interest pertaining to this
Bloomsburg University. Dr. Avillion has held a variety of nursing course.
positions as a staff nurse in critical care and physical medicine
Content Reviewer: Mary C. Ross, RN, PhD, is an experienced
and rehabilitation settings, as well as numerous leadership roles
nursing educator with extensive clinical experience in multiple
in professional development. She has published extensively and
areas of nursing. She is a retired Air Force flight nurse and
is a frequent presenter at conferences and conventions devoted
previous chair of a national Veterans Administration Advisory
to the specialty of continuing education and nursing professional
Council. She has extensive experience in nursing and has
development. Dr. Avillion owns and is the CEO of Strategic
numerous publications.
Nursing Professional Development, a business that specializes in
Mary Ross has disclosed that she has no significant financial
or other conflicts of interest pertaining to this course.
Course overview
The purpose of this course is to provide nurses with information diseases and how to work with patients and families to reduce
that will enhance their knowledge of vaccine preventable the threat of acquiring such diseases.
Learning objectives
Upon completion of the course, the learner should be able to do Describe the pathophysiology of various vaccine-preventable
the following: diseases.
Identify diseases for which vaccines are administered. Evaluate treatment initiatives, including prevention
Discuss why some parents and other individuals are reluctant strategies, for various vaccine-preventable diseases,
to immunize. Identify potential consequences of not including COVID. Discuss nursing considerations related to
obtaining recommended immunizations. Identify factors that vaccine-preventable diseases.
contraindicate immunization.
● Read the entire course online or in print which requires a 10- ● Depending on your state requirements you will be asked to
hour commitment of time. complete either:
● Complete the self-assessment quiz questions either ○ An affirmation that you have completed the
integrated throughout or all at the end of the course. educational activity.
○ These questions are NOT GRADED. The correct answer ○ A mandatory test (a passing score of 70 percent is
is shown after you answer the question. The questions required). Test questions link content to learning
are included to help affirm what you have learned from objectives as a method to enhance individualized
the course. learning and material retention.
○ The correct answer is shown after the question is ● If requested, provide required personal information and
answered. If the incorrect anser is selected, a rationale payment information.
for the correct answer is provided. ● Complete the MANDATORY Course Evaluation.
CE Broker reporting
are licensed in Arkansas, District of Columbia, Florida, Georgia, be automatically reported for you..
Activity director

Disclosures
course activity.
Disclaimer
Course verification
INTRODUCTION
The burden of contagious diseases has been significantly Vaccines have been administered as a disease-prevention
reduced through the use of successful vaccination programs in strategy for centuries. For example, attempts to inoculate people
the United States. However, outbreaks of contagious illnesses against smallpox were noted as long ago as the 1100s, when
continue to occur throughout the country. Vaccinations are dried scab material from smallpox patients was transferred to
the most important tool available to United States healthcare healthy children and adults. Centuries later, in 1796, Dr. Edward
providers to maintain low levels of contagious diseases. Jenner inoculated an 8-year-old boy with matter from a fresh
Immunization rates in the United States are high, but gaps smallpox lesion and concluded that protection from the disease
in care exist throughout the country. Economic and racial was complete (Immunization Action Coalition, 2021). Today,
disparities exist, leaving vulnerable populations at a higher risk vaccines have been developed to prevent numerous, potentially
for contracting and transmitting contagious diseases. deadly, diseases, yet a considerable number of people do not
The majority of vaccines are administered to healthy receive recommended immunizations.
babies, children, and adults. It is essential that vaccines are Why do some people refuse vaccination while others do not?
demonstrated to be safe as well as effective. Ensuring their What vaccine-preventable diseases pose a threat in the 21st
safety and effectiveness is among the top priorities of the Food century? What are the potential consequences of such diseases?
and Drug Administration (FDA; FDA, 2019) This education program addresses these questions as well
as important nursing considerations for dealing with vaccine-
preventable diseases.
DISEASES FOR WHICH VACCINES ARE ADMINISTERED
Historically, vaccine development progressed at a fairly slow ● Hepatitis A.
rate until the last several decades, when dramatic advances ● Hepatitis B.
in technology and scientific discoveries led to amazingly swift ● Human papillomavirus (HPV).
advances in molecular biology, virology, and immunology. ● Influenza.
These advances have helped to facilitate significant progress in ● Measles.
developing new vaccines (Immunization Action Coalition, 2021). ● Meningitis.
● Mumps.
A number of factors influence vaccine recommendations, ● Pneumonia.
including new discoveries pertaining to diseases and their ● Polio.
prevention, advances in treatment, and vaccine trials. Healthcare ● Rotavirus.
professionals would be wise to consult the Centers for Disease ● Rubella.
Control and Prevention (CDC) website (https://www.cdc. ● Tetanus.
gov) for the latest information on immunization schedules, ● Varicella (chickenpox).
recommendations, catch-up recommendations for children and Vaccines for adults include the following:
adolescents who have not received immunization according to ● Boosters for childhood vaccines as needed.
recommendations, and changes in recommendations. ● Shingles.
Vaccines are recommended in children from birth to 18 years of ● Pneumonia.
age to prevent the following diseases (CDC, 2020i; CDC, 2020q): ● Influenza.
● Acellular pertussis. ● Tetanus.
● Diphtheria. COVID vaccines are discussed later in this course.
● Haemophilus influenzae type b.
WHY DO PARENTS REFUSE OR DELAY VACCINATING THEIR CHILDREN?
Laws regarding immunization and school attendance were whooping cough, and polio (National Conference of State
first enacted to control smallpox outbreaks. As time went on, Legislation, 2021).
such laws have subsequently been used to prevent epidemics In most states unvaccinated children may attend school or day
of vaccine-preventable diseases such as measles, mumps, care if they acquire appropriate exemptions. However, if an

outbreak of vaccine- preventable diseases occurs, children who example, measles was considered to be eradicated in the US
have not been vaccinated are often prohibited from attending in 2000. However, in 2019, one of the worst measles outbreaks
school or day care until the risk of contracting the diseases is in recent years occurred (World Innovation Summit for Health,
over (National Conference of State Legislation, 2021). 2019). Measles cases were reported in 31 states with more than
Although the majority of children in the United States receive 207,000 deaths.
recommended immunizations, significant numbers still do not. Even though there are no federal laws regarding vaccine
The most recent available data from CDC show that the percent immunization, each state has enacted laws dictating which
of children aged 19 to 35 months receiving vaccinations is as vaccinations are required for children before entering schools.
follows (CDC, 2020g): All 50 states have legislation requiring specified vaccines for
● Diphtheria, tetanus, pertussis (4+ doses DTP, DT, or DTaP): students. However, although exemptions vary from state to
83.2 %. state, all school immunization laws allow medical exemptions for
● Polio (3+ doses): 92.7%. some children (National Conference of State Legislation, 2021).
● Measles, mumps, rubella (MMR; 1+ doses): 91.5%. Examples of such medical exemptions include children who are
● Haemophilus influenzae type b (Bb; primary series + booster allergic to the vaccine’s components or those with compromised
dose): 80.7%. immune systems. Forty-five states and Washington, D.C., grant
● Hepatitis B (Hep B; 3+ doses): 91.4%. religious exemptions for people who have religious objections
● Varicella (1+ doses): 91%. to immunizations. As of this writing, 15 states allow philosophical
● Pneumococcal conjugate vaccine (PCV; 4+ doses): 82.4%. exemptions for those who object to immunizations because
● Combined seven-vaccine series: 70.4%. of personal, moral, or other beliefs (National Conference of
According to CDC, 2019 data regarding the percentage of State Legislation, 2021). Examples of such medical exemptions
persons of all ages who received the influenza vaccine shows the include children who are allergic to the vaccine’s components or
following (CDC, 2020h): those with compromised immune systems. Forty-five states and
● Percent of children aged 6 months to 17 years who received Washington, D.C., grant religious exemptions for people who
an influenza vaccination during the past 12 months: 50.4%. have religious objections to immunizations. As of this writing,
● Percent of adults aged 18 to 49 who received an influenza 15 states allow philosophical exemptions for those who object
vaccination during the past 12 months: 34.2%. to immunizations because of personal, moral, or other beliefs
● Percent of adults aged 50 to 64 who received an influenza (National Conference of State Legislation, 2021).
vaccination during the past 12 months: 46.8% .
● Percent of adults aged 65 and over who received an Nursing consideration: Data and legislation regarding
influenza vaccination during the past 12 months: 68.7%. immunization can change without much warning. Nurses
should consult resources in their respective states to stay up to
CDC also reported that in 2019 there were 5,902 influenza- date on laws that dictate vaccination requirements.
related deaths, or 1.8 per 100,000 population (CDC, 2020b).
In 2018, 68.9% of adults 65 and older received a pneumococcal In 2019 the following legislation was enacted (National
vaccination. The number of pneumonia-associated deaths was Conference of State Legislation, 2021):
43,881, or 13.4 per 100,000 population. Additionally, 1.5 million ● Washington state House Bill 1638 removes the personal
visits to the emergency department recorded pneumonia as the belief exemption for the measles, mumps, and rubella
primary hospital discharge diagnosis (CDC, 2020o). vaccine requirement for public schools, private schools, and
Vaccination is considered to be one of the most cost-effective day care centers.
ways of avoiding the spread of disease. An estimated 2 million ● Maine House Bill 586 removes personal and religious belief
to 3 million deaths a year are prevented by vaccinations. An exemptions for public school immunization requirements.
additional 1.5 million deaths could potentially be avoided if the ● New York Senate Bill 2994 removes the religious exemption
global coverage of vaccines were to improve (World Innovation for public school immunization requirements.
Summit for Health, 2019). The reasons for refusal to vaccinate typically fall into the
But vaccine hesitancy (defined as the reluctance or refusal to following four broad categories:
vaccinate despite availability and access to vaccines) is a serious ● Religious reasons.
threat to the progress that has been made in reducing the ● Philosophical reasons.
occurrence of vaccine-preventable diseases. In 2019, the World ● safety concerns.
Health Organization (WHO) named vaccine hesitancy as one ● The need for more education.
of the world’s top 10 global threats. Diseases that were once (McKee & Bohannon, 2016; World Innovation Summit for Health,
considered to be eradicated in the US are coming back. For 2019).
RELIGIOUS REASONS
Religious beliefs are among the most common reasons given for that contracting the disease is God’s will and should not be
choosing not to vaccinate. Currently, 45 states and Washington interfered with by immunization.
D. C. grant religious exemptions for people who have religious According to 2019 available data regarding existing statutes,
objections to immunization. Religious beliefs are usually linked the existing statutes in Minnesota and Louisiana do not explicitly
to core beliefs and personal morals, making it difficult to recognize religion as a reason for exemption. However, the
convince parents and caregivers of the value of immunization. nonmedical exemption may encompass religious beliefs. In
Additionally, people who refuse vaccinations because of religious Virginia parents can receive a personal exemption only for the
beliefs are most often among those who refuse all vaccines HPV vaccine. Missouri’s personal belief exemption does not apply
rather than a specific one (McKee & Bohannon, 2016; World to public schools; it applies only to childcare facilities (National
Innovation Summit for Health, 2019). Some individuals believe Conference of State Legislation, 2021).
PERSONAL BELIEFS OR PHILOSOPHICAL REASONS
Currently, 16 states allow exemptions for religious and personal ● North Dakota.
beliefs (Bean, 2020b): ● Ohio.
● Arizona. ● Oklahoma.
● Arkansas. ● Oregon.
● Colorado. ● Pennsylvania.
● Idaho. ● Texas.
● Louisiana. ● Utah.
● Michigan. ● Washington state.
● Minnesota. ● Wisconsin.

SAFETY CONCERNS
Arguably, the most commonly cited reason for refusing is often the source of much inaccurate information about
vaccinations is the concern for children’s safety. Safety fears can vaccines (Word Innovation Summit for Health, 2019).
be triggered by the following factors (McKee & Bohannon, 2016; Some fear that giving multiple vaccines at the same time, or in
World Innovation Summit for Health, 2019). close proximity, increases the risk of adverse reactions. Thus,
some parents and caregivers may choose to delay vaccinations
Nursing consideration: Healthcare consumers are in opposition to the recommended schedule (World Innovation
constantly assailed with information about vaccines from Summit for Health, 2019).
friends, family, social media, and the Internet, as well as
from healthcare professionals. Unfortunately, not all of the Many Internet reports that contribute to vaccine hesitancy are
information provided is accurate. Nurses are obligated to based on a report published in The Lancet 6 years ago. The
provide information about vaccines that is accurate and report, published by a physician, claimed that there is a link
comprehensible to the healthcare consumer. Nurses should between autism and vaccines (specifically the measles, mumps,
also provide information about which Internet sites can provide and rubella [MMR] vaccine). The conclusions from this study were
reliable and accurate information, such as CDC (https://www. vague and not based on statistically valid data. The study was
cdc.gov) and the Mayo Clinic (https://www.mayoclinic.org). subsequently retracted by The Lancet. Nevertheless, the study is
used by some vaccine hesitancy groups as “proof” that vaccines
Information received from family members, acquaintances, are harmful (World Innovation Summit for Health, 2019).
and/or the media cant cause parents and caregivers to doubt Fears that the vaccine will actually cause the disease they
the safety of vaccines. Information from the media is often are administered to prevent have also been cited as a safety
sensationalized to obtain higher ratings. Such information is concern. Some people are convinced that immunizations
often inaccurate without objective scientific review. The Internet ultimately cause serious illness (World Innovation Summit for
Health, 2019).
NEED FOR EDUCATION
The fourth reason for vaccine refusal involves parents and researchers support the safety and efficacy. Serious side effects
individuals expressing a need for more information about the are rare. The benefits of being vaccinated far exceed the risk
immunization process. They need to receive accurate information for possible side effects.
about both the benefits and risks of each recommended vaccine. ● Vaccination of children contributes to herd immunity. Herd
Healthcare professionals must hold objective conversations immunity is defined as the point at which a sufficient number
about vaccination and encourage open discussion, including of people are immune to infection so that people who are
being willing to answer any and all questions and address fears not immune are not infected. If enough of the population
and concerns without bias (McKee & Bohannon, 2016; World is immune to a disease, transmission can be reduced and
Innovation Summit for Health, 2019). vulnerable individuals are protected.
Parents and other adults often want more information about ● Immunizations can save time and money. Children with some
vaccine risks as well as benefits. They want detailed information vaccine-preventable diseases can be denied attendance at
that is based on facts and is nonbiased. It is important that some schools, and adults may be prohibited from some job
information be provided in ways that are understood by people opportunities in healthcare or the military. These types of
without a healthcare background (World Innovation Summit for diseases can lead to long-term disabilities that can result in
Health, 2019). significant medical bills and caregiver’s lost time at work.
The following statements show the importance of vaccination Nursing consideration: If children are not vaccinated, there
(World Innovation Summit for Health, 2019): is the risk of harm not only to themselves, but to possibly
● Immunizations can save the lives of children by protecting exposing other children and families to vaccine-preventable
them against diseases that once killed thousands of people. diseases. The choice of whether or not to vaccinate affects
Several diseases have been completely eradicated in the US, an entire population (World Innovation Summit for Health,
such as polio. Currently, there are no reports of polio in the 2019). Transmission of preventable diseases such as pertussis
US. The history of vaccination shows that vaccinations are safe can endanger the lives of elderly persons or those who are
and effective. Review by physicians, scientists, and healthcare immunosuppressed.
Case study 1: Mrs. Maran and her daughter

Mrs. Maran is strongly opposed to the administration of vaccines Discussion 2: According to 2019 available data, the
and has received a personal exemption for immunization based existing statutes in Minnesota and Louisiana do not
on personal beliefs. She believes that vaccines are linked to the explicitly recognize religion as a reason for exemption.
development of disease and that they are also responsible for However, the nonmedical exemption may encompass
long-term, chronic conditions such as autism spectrum disorder. religious beliefs. In Virginia, parents can receive a personal
Mrs. Maran believes that natural immunity is best. She thinks it is exemption only for the HPV vaccine. Missouri’s personal
better to acquire immunity naturally without injecting chemicals belief exemption does not apply to public schools. It
into the body. Her daughter is 4 years old and has not received applies only to childcare facilities (National Conference of
any of the recommended childhood immunizations. Mrs. Maran
State Legislation, 2021).
and her family recently moved to Missouri and she is thinking
of investigating the public school system associated with her Question 3:Mrs. Maran cites personal beliefs as her reason for
new home. She is confident that she will be able to receive a objecting to vaccination. What do personal beliefs encompass
personal belief exemption from vaccination as she prepares her when talking about distrust of vaccines?
daughter for entrance into the public school system. Discussion 3: Personal beliefs or philosophical reasons
Question 1: Will Mrs. Maran be able to use personal belief encompass a wide variety of issues. For example, some
objections to avoid having her daughter immunized? people believe that it is beneficial for children to contract
Discussion 1: In Missouri, personal belief exemption does certain vaccine-preventable diseases. They believe
not apply to public schools. It applies only to childcare that natural immunity, acquired by actually having the
facilities. Mrs. Maran will not be able to claim personal disease, is better than immunity gained from vaccination.
beliefs to obtain an exemption. Some people believe that vaccines do more harm than
good and cause disease and long-term adverse effects.
Question 2: What other states have limitations on exemptions Additional reasons that are part of personal beliefs or
because of 2019 legislation? philosophical reasons include believing that the diseases

for which vaccinations are available are no longer a threat, preventable diseases are contracted, they are easily
assuming that the possible negative side effects outweigh treatable and are not serious.
the benefits of vaccination, and believing that if vaccine-
POTENTIAL CONSEQUENCES OF NOT OBTAINING RECOMMENDED IMMUNIZATIONS
The most obvious potential consequence of failure to obtain
recommended immunizations is development of the disease Nursing consideration: Some parents may believe that most
and the risk of its complications. Acquiring vaccine-preventable vaccine-preventable diseases no longer occur in the United
diseases may have serious, even fatal, consequences. For States; therefore, they believe that vaccine administration
example, the CDC reported the estimated range of annual is not necessary. It is important to teach parents and other
burden of flu in the US from 2010 to 2020 resulted in an caregivers that diseases – such as whooping cough, measles,
estimated 9 million to 45 million illnesses; between 140,000 chickenpox, meningitis, and influenza – still circulate in the
and 810,000 hospitalizations; and between 12,000 and 61,000 United States. Effects of such diseases can range from mild to
deaths annually since 2010 (CDC, 2019n; CDC, 2020e). severe and life threatening.
Consequences for children

If parents choose not to vaccinate or to delay vaccination of Make sure that all members of the healthcare team who
their children, they must understand a number of important come into contact with the child know that the child has
issues and take appropriate actions. Such actions include not been vaccinated. This helps to prevent spread of
maintaining a written record of the child’s vaccination status the disease. Learn about possible exposure to diseases
(CDC, 2019n; ImmunizeBC, 2020). This record should be common in certain geographic areas before traveling with
easily accessible. If a child becomes ill or injured, healthcare an unvaccinated child. Vaccine-preventable diseases are
providers must know what immunizations the child has or common throughout the world, including Europe. Consult
has not received or if immunizations were not administered CDC travelers’ information website before traveling at www.
according to recommended schedules. Under stress, parents cdc.gov/travel
may not remember the details of the child’s immunization ● If, while traveling, an unvaccinated person develops a
status. Healthcare providers must be able to quickly access vaccine-preventable disease, they should not travel by plane,
this information. Make sure that all of the child’s physicians train, or bus, and should follow medical recommendations
and healthcare providers are aware of the child’s immunization regarding isolation until the person is no longer contagious.
status. This is especially important if an outbreak of vaccine- ● Seek immediate medical help if a child or any members of
preventable diseases occurs. their family develop early signs and symptoms of vaccine-
Physicians, other healthcare professionals, and parents/ preventable disease. When visiting healthcare providers or
caregivers can take steps to help protect the child against such emergency departments, inform staff members that the child
diseases (CDC, 2019n; ImmunizeBC, 2020): has not been vaccinated before there is contact with the
● Contact the child’s physician immediately if the child has child or family members.
been exposed to a vaccine-preventable disease but has ● Consult with the child’s physician for the latest information
not been vaccinated against that disease. In some cases, about vaccines. Visit CDC website www.cdc.gov/vaccines
vaccination may still be possible. ● Older adults should be cautious when taking care of
● Know that if an outbreak of vaccine-preventable diseases unvaccinated children.
occurs in the children’s school or day care center, they may
be asked to take their unvaccinated child out of school or Nursing consideration: Nurses have an obligation to explain
day care until it is deemed safe for them to return. This can the consequences of failing to immunize children to parents
take from several days up to several weeks. and caregivers. Parents and caregivers must have the most
● Learn early signs and symptoms of vaccine-preventable accurate, current information so that they can make informed
disease. If a child develops symptoms of such a disease, decisions about immunization.
parents should notify the child’s physician immediately.
Consequences for adults
According to a 2016 National Health Interview Survey, many ● 3.4 percentage points to 26.6% overall.
adults are not aware that they need vaccines at regular intervals ● Hepatitis A vaccination increased by 14.8 percentage points
(CDC, 2018b; CDC, 2018e; CDC, 2020z). to 23.7% among adults 19 to 49 years of age with chronic
● Compared with the 2015 survey data, there was a modest hepatic conditions. Herpes zoster (shingles) vaccination
increase in vaccination coverage for some vaccines and increased 2.8 percentage points to 33.4% among adults 60
age groups. However, coverage decreased for one vaccine and older, and increased 3.1 percentage points to 37.4%
overall and in two age groups in one racial/ethnic category. among adults 65 and older. HPV vaccination (at least one
Apart from these findings, vaccination coverage among dose) among females and males 19 to 26 who had not
adults in 2016 was similar to estimates from 2015. received HPV vaccination before age 19 was 8.6% and 2.7%,
● Overall, influenza vaccination decreased 3.1 percentage respectively.
points to 70.4% among adults > 65 years of age and ● Racial and ethnic vaccination differences persisted for
decreased among whites in all age groups except among all vaccinations. Coverage was generally lower for most
adults aged 19 to 49 years. Pneumococcal vaccination vaccinations among non- Hispanic and non-Hispanic Asian
increased 3.3 percentage points to 66.9% among adults > 65 adults compared to White adults. Vaccination differences
years of age. widened for Tdap (African Americans, all age groups) and
● Vaccination of adults 19 years and older with tetanus toxoid, Herpes Zoster (Asians > 65 years). This was primarily because
reduced diphtheria toxoid, and acellular pertussis vaccine of increases in Whites receiving vaccinations.
(Tdap) increased by
RECOMMENDED ADULT IMMUNIZATIONS (CDC, 2020V; CDC, 2020W)
● Influenza (flu) inactivated (IIV) or influenza recombinant (RIV) ● Varicella (VAR): two doses for persons 19 to 40 (if born in
vaccine: One dose annually, or influenza live attenuated 1980 or later): Adults over the age of 45 should receive two
(LAIV) one dose annually. doses.
● Tetanus, diphtheria, pertussis (Tdap or Td): One dose Tdap ● Zoster recombinant (RZV): Preferred two doses for persons
and then Td or Tdap booster every 10 years. aged 50 years of age or older.
● Measles, mumps, rubella (MMR): One or two doses ● HPV vaccine is recommended for routine vaccination (for
depending on indication (if born in 1957 or later). both males and females) at age 11 or 12, but vaccination
can be started at age 9. For adults it is recommended that ● Meningococcal B (MenB): Administered as two or three
everyone through age 26 years should be vaccinated if doses depending on vaccine and indication for persons 19
not adequately vaccinated previously. Vaccination is not years of age and older.
recommended for everyone older than age 26. However, ● Haemophilus influenzae type b (Hib): Administered as one or
some adults ages 27 through 45 may decide to get the HPV three doses depending on indication for persons 19 years of
vaccine based on discussion with their clinicians if they were age and older.
not adequately vaccinated when they were younger. ● Current recommendations for COVID vaccines vary by state
● Pneumococcal vaccination with pneumococcal conjugate and whether the immunization is by Moderna, Pfizer, or
(PCV13): Persons 19 to 64 years of age with certain medical Johnson & Johnson.
conditions should receive one dose. Persons 65 years of age
and older should receive one dose. Nursing consideration: Certain vaccines may have been
● Pneumococcal vaccination with (PPSV23): Recommendations administered in childhood, which may alter timing or the
for persons 19 to 64 years of age is one or two doses need for adult immunizations. For example, adults receive
depending on indication. For persons 65 years of age and the varicella vaccine only if they did not receive it as children
older, one dose should be administered. or did not have varicella (chickenpox). Some vaccines
● Hepatitis A (HEPA): Vaccine is administered in two or three are recommended for adults with certain risks related to
doses depending on vaccine for persons 19 years of age and their health, job, or lifestyle. Before receiving any type of
older. vaccination, adults should review their immunization status
● Hepatitis B (HEPB): Vaccine is administered in two or three with their healthcare providers. Additionally, CDC website
doses depending on vaccine for persons 19 years of age and offers current information about recommended immunization
older. schedules at www.cdc.gov/vaccines
● Meningococcal A, C, W, Y (MenACWY): Administered as one
or two doses depending on indication.
TEN REASONS FOR ADULTS TO RECEIVE RECOMMENDED IMMUNIZATIONS
There are numerous reasons adults should receive 5. Lack of immunization can cause people to miss out on
recommended immunizations, including the following 10 important activities such as work and social events. In
important issues (MD Monthly Staff, 2019). addition to financial compromise as a result of lost work
1. Vaccines reduce the spread of disease. Herd immunity, one time, quarantine may be necessary, and a significant
of the goals of vaccination, is described as “even if vaccines disruption of interpersonal relationships may occur.
are not 100% effective, having a large enough percentage 6. The cost of disease is significantly more than the cost
of the population vaccinated against disease will protect of vaccination. For example, measles may lead to
everyone, even those in whom the vaccine is not effective.” hospitalization and meningitis could be fatal. The cost
The vaccine rate necessary for herd immunity differs among of contracting a vaccine-preventable disease can lead to
various diseases but is typically about 60% to 80% of the severe financial compromise.
population. 7. Travel may be limited without vaccination. Many countries
2. Vaccines reduce the incidence of serious health mandate vaccinations for those who want to visit.
complications. Even though vaccines do not always International travel nearly always requires vaccinations.
completely eliminate the possibility of contracting a specific 8. Vaccines do not cause disease. A concern often cited by
disease, the risk is greatly decreased. If someone who those who oppose vaccination is that vaccines cause the
has been vaccinated does develop a disease for which disease they are supposed to prevent. This is inaccurate.
vaccination has been obtained, the chances of having There are no living pathogens in vaccines that are able to
serious complications are significantly less. cause disease.
3. Vaccines reduce the risk of death. For example, before the 9. Thimerosal is no longer a component of most vaccines.
development of the measles vaccine, more than 500,000 Except for certain versions of the flu vaccine, vaccines do
children contracted the disease each year and about 500 not contain thimerosal. Although no disease has been linked
died from the disease. Children younger than 5 years of to thimerosal in scientific research, vaccine manufacturers
age and adults older than 20 years of age are more likely to have switched to other types of preservatives.
suffer from serious complications such as pneumonia and 10. Vaccination is not linked to autism. Extensive research over
encephalitis. many years has shown that autism is not linked to, or caused
4. Some individuals are not able to receive vaccines. Allergies by, vaccines. There is also no evidence to suggest that
to vaccine components or people with compromised vaccines negatively impact development or cause disability.
immune systems are examples of reasons that vaccines may There is evidence, however, to support vaccination as a
be contraindicated. Those who can be vaccinated help to means of preventing disease, disability, and death.
raise herd immunity and protect people who cannot receive
vaccines.
PEOPLE WHO SHOULD NOT RECEIVE VACCINATIONS
Age, health status, and other factors influence whether or not website (www.cdc.gov/vaccines) also offers significant information
people should receive certain immunizations. The following about vaccine contraindications (CDC, 2020x).
summary provides information about contraindications for certain Guidelines for vaccine contraindications include, but are not
vaccines. For detailed information about vaccine contraindications, limited to, the following.
patients should consult with their healthcare providers. CDC
Diphtheria, tetanus, and acellular pertussis (DTaP vaccine)
Some children should not get the DTaP vaccine or should wait. ● Those who have had seizures or another nervous system
These include the following (CDC, 2020cc): problem. Those who have ever had Guillain-Barré syndrome
● Those who have had an allergic reaction after a previous (GBS).
dose of any vaccine that protects against tetanus, diphtheria, ● Those who have had severe pain or swelling after a previous
or pertussis, or have any severe or life-threatening allergies. dose of any vaccine that protects against tetanus or diphtheria.
● Those who have had a coma, decreased level of In some cases, a child’s healthcare provider may decide to
consciousness, or prolonged seizures within 7 days after a postpone DTaP vaccination to a future visit. Children with minor
previous dose of any pertussis vaccine (DTP or DTaP). illnesses such as a cold may be vaccinated. Children who are
moderately or severely ill should usually wait until they recover
before getting DTaP (CDC, 2020cc).

Hepatitis A vaccine
Some people should not receive the hepatitis A vaccine or should People with minor illnesses such as a cold may be vaccinated.
wait to receive it if they have had an allergic reaction after a People who are moderately or severely ill should usually wait until
previous dose of hepatitis A vaccine or have any severe or life- they recover before getting hepatitis A vaccine (CDC, 2020cc).
threatening allergies. In some cases, healthcare providers may
decide to postpone vaccination (CDC, 2020cc).
Hepatitis B vaccine
Some people should not receive the hepatitis B vaccine or should People with minor illnesses such as a cold may be vaccinated.
wait to receive it if they have had an allergic reaction after a People who are moderately or severely ill should usually wait until
previous dose of hepatitis B vaccine or have any severe or life- they recover before getting hepatitis B vaccine (CDC, 2020cc).
threatening allergies. In some cases, healthcare providers may
decide to postpone vaccination (CDC, 2020cc).
HPV (human papillomavirus) (HPV) vaccine
People should not get this vaccine if they have had an allergic In some cases, healthcare providers may decide to postpone
reaction after a previous dose of HVP vaccine, have any severe HPV vaccination to a future visit. People with minor illnesses
or life-threatening allergies, or they are pregnant (CDC, 2020cc). such as a cold may be vaccinated. People who are moderately or
severely ill should usually wait until they recover before getting
HPV vaccine (CDC, 2020cc).
Influenza (live) vaccine
Before receiving the vaccine, the person or a caregiver must ● Has other underlying medical conditions that can put
inform healthcare providers if the patient (CDC, 2020cc): people at higher risk of serious flu complications such
● Is younger than 2 years or older than 49 years of age. as lung disease, heart disease, kidney disease, kidney or
● Is pregnant. liver disorders, neurologic or neuromuscular, or metabolic
● Has had an allergic reaction after a previous dose of influenza disorders.
vaccine or has any severe or life-threatening allergies. ● Has had Guillain-Barré Syndrome (GBS) within 6 weeks after
● Is a child or adolescent 2 through 17 years of age who is a previous dose of influenza vaccine.
receiving aspirin or aspirin-containing products. In some cases, a healthcare provider may decide to postpone
● Has a weakened immune system. influenza vaccination to a future visit. For some patients a
● Is a child 2 through 4 years old who has asthma or a history different type of influenza vaccine (inactivated or recombinant
of wheezing in the past 12 months. influenza vaccine) might be more appropriate than live
● Has taken influenza antiviral medication in the previous 48 attenuated influenza vaccine. People with minor illnesses such
hours. as a cold may be vaccinated. People who are moderately or
● Cares for severely immunocompromised persons who require severely ill should usually wait until they recover before getting
a protected environment. influenza vaccine (CDC, 2020cc).
● Is 5 years or older and has asthma or respiratory compromise.
Influenza (inactivated) vaccine
Before receiving this vaccine, healthcare providers should be In some cases, the healthcare provider may decide to postpone
informed if the person getting the vaccine has had an allergic influenza vaccination to a future visit. People with minor illnesses
reaction after a previous dose of influenza vaccine, has any such as a cold may be vaccinated. People who are moderately or
severe or life-threatening allergies, or has ever had GBS (CDC, severely ill should usually wait until they recover before getting
2020cc). influenza vaccine (CDC, 2020cc).
Measles, mumps, rubella (MMR) vaccine
Some people should not receive the MMR vaccine or should wait ● Have ever had a condition that makes them bruise or bleed
before receiving it if they (CDC, 2020cc): easily.
● Have had an allergic reaction after a previous dose of MMR ● Have recently had a blood transfusion or received other
or MMRV vaccine or have any severe or life-threatening blood products.
allergies. ● Have tuberculosis.
● Are pregnant or think they might be pregnant. ● Have gotten any other vaccines in the past 4 weeks.
● Have a weakened immune system or have a parent, brother, People with minor illnesses such as a cold may be vaccinated.
or sister with a history of hereditary or congenital immune People who are moderately or severely ill should usually wait
system problems. until they recover before getting MMR vaccine (CDC, 2020cc).
Measles, mumps, rubella, and varicella (MMRV) vaccine
Before receiving the vaccine, healthcare providers should be ● Has recently had a blood transfusion or has received other
informed if the person getting the vaccine (CDC, 2020cc): blood products.
● Has had an allergic reaction after a previous dose of ● Has tuberculosis.
MMRV, MMR, or varicella vaccine, or has any severe or life- ● Has gotten any other vaccines in the past 4 weeks.
threatening allergies. In some cases, a healthcare provider may decide to postpone
● Is pregnant or thinks pregnancy is a possibility MMRV vaccination to a future visit or may recommend that
● Has a weakened immune system or has a parent, brother, the child receive separate MMR and varicella vaccines instead
or sister with a history of hereditary or congenital immune of MMRV. People with minor illnesses such as a cold may be
system problems. vaccinated. Children who are moderately or severely ill should
● Has ever had a condition that makes them bruise or bleed usually wait until they recover before getting MMRV vaccine
easily. (CDC, 2020cc).
● Has a history of seizures or has a parent, brother, or sister
with a history of seizures.
● Is taking, or plans to take, salicylates such as aspirin.

Shingles (herpes zoster) vaccine
Before receiving this vaccine, healthcare providers must be In some cases, the healthcare provider may decide to postpone
informed if the person getting the vaccine has had an allergic shingles vaccination to a future visit. People with minor illnesses
reaction after a previous dose of shingles vaccine, has any severe such as a cold may be vaccinated. People who are moderately or
or life-threatening allergies, is pregnant or breastfeeding, or is severely ill should usually wait until they recover before getting
currently experiencing an episode of shingles (CDC, 2020cc). shingles vaccine (CDC, 2020cc).
Meningococcal vaccines
For both the Serogroup B Meningococcal (MenB) and breastfeeding are not reasons to avoid Meningococcal ACWY
Meningococcal ACWY (MenACWY) vaccine, healthcare providers vaccination. A pregnant or breastfeeding woman should be
must be informed before giving the vaccine if the person has vaccinated unless it is specifically contraindicated. People with
had an allergic reaction after a previous dose of meningococcal minor illnesses such as a cold may be vaccinated. People who
vaccines or has any severe or life- threatening allergies (CDC, are moderately or severely ill should usually wait until they
2020cc). recover before getting Meningococcal ACWY vaccine (CDC,
Not much is known about the risks of this vaccine for a pregnant 2020cc).
woman or breastfeeding mother. However, pregnancy or
PCV13 (pneumococcal conjugate) vaccine
The person getting the vaccine should inform the healthcare In some cases, the healthcare provider may decide to postpone
provider if they have had an allergic reaction after a previous PCV13 vaccination to a future visit. People with minor illnesses
dose of PCV13, to an earlier pneumococcal conjugate vaccine such as a cold may be vaccinated. People who are moderately or
known as PCV7, or to any vaccine containing diphtheria toxoid severely ill should usually wait until they recover before getting
(for example, DTaP), or has any severe or life-threatening PCV13 (CDC, 2020cc).
allergies (CDC, 2020cc).
PPSV23 (pneumococcal polysaccharide) vaccine
Before getting the vaccine, healthcare providers should be told In some cases, the healthcare provider may decide to postpone
if the person receiving the vaccine has had an allergic reaction PPSV23 vaccination to a future visit. People with minor illnesses
after a previous dose of PPSV23 or has any severe or life- such as a cold may be vaccinated. People who are moderately or
threatening allergies (CDC, 2020cc). severely ill should usually wait until they recover before getting
PPSV23 (CDC, 2020cc).
Polio vaccine
Before administering the vaccine, healthcare providers should be In some cases, the healthcare provider may decide to postpone
informed if the patient has had an allergic reaction after a previous polio vaccination to a future visit. People with minor illnesses
dose of polio vaccine or has any severe or life-threatening such as a cold may be vaccinated. People who are moderately or
allergies (CDC, 2020cc). severely ill should usually wait until they recover before getting
polio vaccine (CDC, 2020cc).
Rotavirus vaccine
Before administering the vaccine, healthcare providers should be In some cases, the child’s healthcare provider may decide to
informed if the patient (CDC, 2020cc): postpone rotavirus vaccination to a future visit. Infants with
● Has had an allergic reaction after a previous dose of rotavirus minor illnesses such as a cold may be vaccinated. Infants who are
vaccine or has any severe or life-threatening allergies. moderately or severely ill should usually wait until they recover
● Has a weakened immune system. before getting rotavirus vaccine (CDC, 2020cc).
● Has severe combined immunodeficiency (SCID).
● Has had a type of bowel blockage called intussusception.
Adult tetanus and diphtheria vaccine (TD)
Before administering the vaccine, healthcare providers should be ● Has had an allergic reaction after a previous dose of any
informed if the patient has had an allergic reaction after a previous vaccine that protects against tetanus, diphtheria, or pertussis,
dose of any vaccine that protects against tetanus or diphtheria, or has any severe or life-threatening allergies.
has any severe or life-threatening allergies, has ever had GBS, ● Has had a coma, decreased level of consciousness, or
or has had severe pain or swelling after a previous dose of any prolonged seizures within 7 days after a previous dose of any
vaccine that protects against tetanus or diphtheria (CDC, 2020cc). pertussis vaccine (DTP, DTaP, or Tdap).
In some cases, the healthcare provider may decide to postpone ● Has seizures or another nervous system problem.
Td vaccination to a future visit. People with minor illnesses such as ● Has ever had GBS.
a cold may be vaccinated. People who are moderately or severely ● Has had severe pain or swelling after a previous dose of any
ill should usually wait until they recover before getting Td vaccine vaccine that protects against tetanus or diphtheria.
(CDC, 2020cc). In some cases, the healthcare provider may decide to postpone
Before administering the vaccine, healthcare providers should be Tdap vaccination to a future visit. People with minor illnesses
told if the patient (CDC, 2020cc): such as a cold may be vaccinated. People who are moderately or
Tdap vaccine (CDC, 2020cc).
Varicella (chickenpox) vaccine
Before receiving the vaccine, healthcare providers should be told ● Is taking salicylates such as aspirin.
if the patient (CDC, 2020cc): ● Has recently had a blood transfusion or has received other
● Has had an allergic reaction after a previous dose of varicella blood products.
vaccine or has any severe or life-threatening allergies. ● Has tuberculosis.
● Is pregnant or thinks they might be pregnant. ● Has gotten any other vaccines in the past 4 weeks.
● Has a weakened immune system or has a parent, brother, In some cases, the healthcare provider may decide to postpone
or sister with a history of hereditary or congenital immune varicella vaccination to a future visit. People with minor illnesses
system problems.

such as a cold may be vaccinated. People who are moderately or
varicella vaccine (CDC, 2020cc). A 19-year-old patient is going to receive the MMR vaccine.
As a child her immunization schedule was sporadic. She was
raised by a single parent and the family frequently moved
from one state to another. After consulting with her physician,
it is decided that she should receive the vaccine. All of the
following are reasons she should not get the vaccine today
EXCEPT:
a. She is pregnant.
b. She received a COVID-19 vaccine 2 weeks ago.
c. She has a cold.
d. Her brother has a congenital immune system disorder.
VACCINE-PREVENTABLE DISEASES: SMALLPOX
Because immunization programs have significantly decreased the subsequent anthrax attacks through the mail. (U.S.
the incidence of vaccine-preventable diseases, some healthcare Department of Defense, 2002)
professionals may not be as familiar as they should be with After the terrorist attacks on September 11, 2001, authorities
certain diseases. Even smallpox, a disease that has been strongly considered the health status of the American public
declared eradicated, can pose a threat. Consider the following and the very real possibility of terrorists using biologic weapons
information. in future warfare. Although the risk is considered low, there are
President Bush today announced he has ordered concerns that the smallpox virus could be used for bioterrorism.
smallpox vaccinations to begin for military personnel. In 2002, a joint working group consisting of members of the
He has also recommended medical personnel and first Advisory Committee on Immunization Practices and the National
responders receive the vaccine, but on a voluntary basis. Vaccine Advisory Committee met in Atlanta as part of their
Administration officials stopped short of recommending review of smallpox vaccine recommendations. As a result of
widespread vaccinations of the American public. ‘Men their recommendations and the occurrence of terrorist events
and women who could be on the frontlines of a biological on American soil, there is now a stockpile of enough smallpox
attack must be protected,’ the president said during an vaccine to vaccinate every person in the United States. This
afternoon press briefing in the Eisenhower Executive Office stockpile also has medications that might help to treat smallpox
Building. The president stressed his decision was not based if individuals contract the disease (CDC, 2016b).
on a specific threat, but on the renewed focus on security
brought about by the Sept. 11, 2001, terrorist attacks and
Storage of the smallpox virus
The last confirmed case of smallpox occurred in the US in 1949. of the smallpox virus from the 1950s at a federal laboratory
Routine smallpox vaccination ended in this country in 1972. near Washington, D.C. This was the second lapse identified
Smallpox was declared eradicated from the planet in 1980, in a month that involved a deadly pathogen at a government
becoming the first time in history that medical scientists and facility. Six glass vials sealed with melted glass that contained
public health workers had completely purged the world of a freeze-dried smallpox virus were found in a cardboard box on
devastating infectious disease (CDC, 2016a). July 1, 2014, at a former lab that was being cleared out on the
However, even though the disease was declared eradicated, National Institutes of Health campus in Bethesda, Maryland. The
samples of the live virus were preserved for research purposes. vials appeared to be intact and there was no evidence that lab
The only verified repositories of the virus are in secure workers or the general public were placed at risk (Kaiser, 2014).
laboratories at CDC in Atlanta and the State Center for Research Although low, the risk of smallpox virus being used as a
on Virology and Biotechnology in Koltsovo, Russia (CDC, 2016a) bioterrorism weapon is real. This warrants nurses and other
There is no known immediate threat of a bioterrorist attack using healthcare personnel to be aware of the pathophysiology of the
the smallpox virus. However, there is concern among health disease, its clinical presentation, and treatment initiatives.
authorities that some countries may have made the virus into
weapons. Such weapons may have fallen (or might fall) into the Nursing consideration: Nurses and other healthcare
hands of terrorists or other people with criminal intent (CDC, professionals must be aware of the continued existence
2016a). of smallpox virus stored in secured laboratories and of the
possibility of some virus samples being stolen for use as
Concerns about using smallpox and other potentially deadly bioterrorism weapons. They must be alert to the possibility of
methods of bioterrorism increased when, on Tuesday, July bioterrorism and how they may be called upon to intervene in
8, 2014, CDC announced that workers discovered stray vials the event of such a disaster.
Description
Smallpox, or variola, is an ancient acute, disfiguring, highly providers. If smallpox is used as a bioterrorism agent, vaccination
contagious infectious disease caused by the variola virus. It is programs are ready to be initiated (CDC, 2016a; CDC, 2016b).
often deadly. Naturally occurring smallpox was eradicated by After the last known naturally occurring case of smallpox in late
1980 (, 2020i). Vaccination is recommended only for certain 1975 in Bangladesh, the only known cases were caused by a
laboratory workers and is offered to members of the military, laboratory accident in 1978 in Birmingham, England, which killed
health department officials, first responders, and key healthcare one person and led to a limited outbreak (CDC, 2016b).
Types of smallpox
There are two clinical forms of smallpox. First is variola major, the 1. Ordinary: Historically, ordinary smallpox occurred most
severe form, which had a case-fatality rate of about 30%. Second frequently.
is variola minor, which occurred less often, is less severe than 2. Modified: This type was mild and occurred in previously
variola major, and had a death rate of 1% or less (FDA, 2018). vaccinated persons.
There are four types of variola major smallpox (FDA, 2018): 3. Flat: Flat type occurred less often than ordinary and
modified but was usually fatal.

4. Hemorrhagic: Hemorrhagic type also occurred less often and was not initially recognized as smallpox by healthcare
than ordinary or modified and was usually fatal. This type providers. Smallpox vaccination does not provide much, if
had a much shorter incubation period than other types any, protection against hemorrhagic smallpox.
Etiology and incidence
Historically, smallpox affected people of all ages throughout contaminated linens or other objects (CDC, 2017; FDA, 2018;
the world. It existed for at least 3,000 years and was fatal, on WHO, 2016).
average, in up to 30% of cases. In temperate zones incidence Smallpox had an incubation period of between 7 and 17 days
was highest during the winter, and in the tropics incidence was after exposure. It was most infectious during the first week of
highest during the hot, dry months. Caused by the variola virus, illness but was contagious from onset until after the last scab was
smallpox was transmitted directly by person-to-person contact shed (CDC, 2017; FDA, 2018; WHO, 2016).
from respiratory droplets or from dried scales of virus- containing
lesions. The virus was transmitted indirectly via contact with
Clinical manifestations
Smallpox was generally transmitted at a slower pace compared
to diseases such as measles or chickenpox. This was because by Nursing consideration: Smallpox patients were most infectious
the time the patients were contagious, they were ill and in bed, during the first week of the rash when large amounts of the
and the disease was spread primarily to household members and virus were found in saliva. Patients were no longer infectious
friends. Large outbreaks in schools were uncommon (CDC, 2017; after all scabs had separated, which was about 3 to 4 weeks
FDA, 2018; WHO, 2016). after the onset of the rash FDA, 2018).
Following the 1- to 2-week incubation period, the pre-eruptive
stage of the disease developed abruptly causing chills, high Figure 1: Smallpox patient
fever, headache, backache, severe malaise, and – especially in
children – vomiting and possible seizures. Occasionally, violent
delirium, stupor, or coma occurred (CDC, 2017; FDA, 2018;
WHO, 2016).
The pre-eruptive stage was followed by the appearance of a
maculopapular rash (eruptive stage) that progressed to papules
1 to 2 days after the rash appeared. Vesicles appeared on the
4th or 5th day, pustules by the 7th day, and scab lesions on the
14th day (CDC, 2017; FDA, 2018; WHO, 2016).
The rash first appeared on the oral mucosa, face, and forearms.
It then spread to the trunk and the legs. Lesions were also found
on the palms and soles. Lesions were deeply embedded in the
dermis and felt like firm, round objects embedded in the skin. As
the lesions healed, scabs separated, and pitted scarring slowly
developed (CDC, 2017; FDA, 2018; WHO, 2016).
Rice. (n.d.b). Smallpox. https://www.cdc.gov/smallpox/images/clini-

cian/clinical-disease- patient.jpg
Diagnosis and treatment

Smallpox was easily recognized before it was eradicated. Today, These drugs have not been tested in people with smallpox.
however, many healthcare professionals are not aware of its Thus, it is unknown whether treatment would help human
characteristic clinical manifestations. It is important that they patients who actually have smallpox. Tecovirimat and cidofovir
become familiar with these manifestations in the event of an are stockpiled by CDC’s Strategic National Stockpile, which
outbreak caused by terrorist activities. Diagnosis was made on has medical supplies to protect the American public if a public
the basis of history, clinical presentation, and isolation of the health emergency involving smallpox occurs (CDC, 2020v).
virus from lesion scrapings and aspirate of vesicles and pustules The replication-competent smallpox vaccines (ACAM2000 and
(CDC, 2017; FDA, 2018; WHO, 2016). APSV) can protect people from getting sick or make the disease
There is no cure for smallpox. Treatment was supportive and less severe if they receive the vaccine either before or within a
included strict isolation treatment of bacterial infections/ week of coming in contact with smallpox virus (CDC, 2020v).
complications (CDC, 2017; CDC, 2020v; FDA, 2018; WHO, Before contact with the virus, the vaccine can protect a person
2016). from getting sick. Within 3 days of being exposed to the virus,
Research indicates that in laboratory tests, tecovirimat has been the vaccine might protect a person from getting the disease. If a
shown to be effective against the variola virus in animals who person still gets the disease, the person might get much less sick
had diseases similar to smallpox. Cidofovir and brincidofovir than an unvaccinated person would. Within 4 to 7 days of being
also have been shown to be effective against the variola virus in exposed to the virus, the vaccine likely gives a person some
animals who had diseases similar to smallpox (CDC, 2017; CDC, protection from the disease. If a person still gets the disease, the
2020v; FDA, 2018; WHO, 2016). person might not get as sick as an unvaccinated person would.
Once a person has developed the smallpox rash, the vaccine will
not protect (CDC, 2020v).
Points about vaccination
Anyone who has received the smallpox vaccination has some level Currently, routine vaccination against smallpox is not
of protection. However, it may not still be fully effective but should recommended for the general public. Vaccine is still administered
protect people from the worst effects of the disease. If exposure is to protect researchers who work with the virus and to certain
likely, a repeat vaccine is recommended (WHO, 2016). military personnel (WHO, 2016).

POLIO
To a polio victim who can no longer breathe for himself, nothing difficult for 21st century practitioners to comprehend. The
is more disheartening than the thought of spending every hour excerpt gives some idea of the hopes of researchers who had
of his life flat on his back in an iron lung. In the past few years, worked on a polio vaccine development since 1949.
the iron lung has been radically altered to make life within it A follow-up article on May 24, 1954, discussed the vaccination
more bearable. By enclosing the patient’s head in a plastic process that occurred during the preceding months. It also
bubble, air can be pumped in and out of his lungs while the discussed the use of gamma globulin as an anti-polio agent.
rest of the machine is removed. Thus, long periods of therapy
and nursing care are possible. Doctors are also experimenting During the last few weeks, the famed Salk polio vaccine
with a new lung in which patients can actually sit up. But most has been given to several hundred thousand children in a
encouraging of all new developments is a breathing technique huge ‘field trial,’ the biggest controlled medical experiment
which enables patients to leave their iron prisons for hours at a ever attempted. Although the results won’t be fully known
time. (Life Magazine, 1953, pp. 127-128) until this winter, the trial has so far gone more smoothly
In just over 67 years, amazing strides have been made to than anyone had a right to expect. The only ill effects have
prevent this devastating disease. Patients once feared spending been a few fainting and lost lunches from the tension and
their lives confined in a cylinder-like breathing apparatus; excitement, and a few cases of allergic reaction from the
others remained physically disabled for the rest of their lives. penicillin included in the vaccine. About three weeks from
The development and administration of the polio vaccine has now, the last shots will be given. The reason for stopping
drastically reduced the occurrence of this disease to primarily the program is the advent of the annual polio “season,”
small outbreaks among unvaccinated populations. when, for reasons unknown, the danger of infection is
The biggest experiment in U.S. medical history will worst. To prevent this seasonal factor from clouding the
take place during the next few months when at least results of the test, the substance that holds such promise
500,000 children will be injected with a vaccine against for ending polio must ironically be put aside just in time
poliomyelitis. Inoculations probably will get under way next when people most need protection. Then what about the
month, in towns throughout the country and will continue children who haven’t been vaccinated – is there any way to
into June. Then local medical teams under the National protect them? … In 1951 and 1952, GG [gamma globulin]
Foundation for Infantile Paralysis will wait and watch as was tested in carefully controlled mass experiments, smaller
the annual curve of polio begins to climb, slowly in June, but similar to the current vaccine trial. Results showed that
higher in July, highest in August and September, then falls if GG were given before a person was exposed to the virus,
steeply again with cool weather. Comparing the amount his chances of getting the disease would be reduced by
of polio among the inoculated children with that among 80 percent for about five weeks – not much protection but
the uninoculated ones, a committee of leading scientists better than nothing. In 1953, GG was released for general
will be able to judge the vaccine’s effectiveness. In theory use in different ways – one way entirely different from the
it should produce immunity against polio in most or all method of 1951 and 1952. Behind the change of method
of the inoculated children. The expectation is that it will lay a wrong but plausible scientific hunch which sprang
produce at least some. Conceivably, it may produce none. from the worthy hope of using GG so as to do the greatest
Suppose it should produce little or none. That would be good for the greatest number. (Life Magazine, 1954, p 8).
a disappointment but would not alter the fact that an Traveling back to the early 1950s shows that researchers were
effective polio vaccine can be and will be made. (Coughlan, as concerned with objective evaluation of vaccine trials as they
1954, p. 121). are today. The use of gamma globulin was also a strategy used
in disease prevention, similar to some prevention efforts today.
Reading this 1954 excerpt from Life Magazine gives the reader
Now, it is known that the polio vaccine strategies initiated in the
a glimpse of what it was like to be on the edge of discovering
1950s were a resounding success. But unlike smallpox, polio has
a vaccine that would theoretically save hundreds of thousands
not been eradicated.
of lives. Medical advances (and communicating such advances)
occurred at a much slower pace in the 1950s, a pace that is
Background
Polio, also referred to as infantile paralysis or poliomyelitis, contaminated water had maternal antibodies and could fight off
ranges in severity from mild flulike symptoms to severe, infection and develop immunity. Advances in hygiene delayed
sometimes fatal, paralytic illness (Mayo Clinic, 2020f). The exposure until children were older and maternal antibodies wore
disease was first recorded in Egyptian carvings dated to off, leaving them with little immunity and significant opportunity
approximately 1400 bc. It circulated at low levels during the for disease development. The disease reached pandemic (an
1800s and was considered relatively uncommon. Advances in epidemic that occurs over a widespread geographic area and
hygiene and improvements in standards of living in the early affects a large proportion of the population) status in Europe,
1900s were thought to contribute to the spread of polio. Infants North America, Australia, and New Zealand during the early
who were once exposed to polio at a very young age through 1940s and 1950s (History of Vaccines, 2018).
Polio is a highly contagious viral illness caused by the poliovirus. over 99% since 1988, the disease still exists. Currently, only three
Between the late 1940s and early 1950s, polio disabled about countries in the world have never stopped transmission of polio:
35,000 annually in the United States alone (National Institute of Pakistan, Afghanistan, and Nigeria. The polio virus can easily be
Neurological Disorders and Stroke, 2020). There is no cure for imported into a polio-free country and can swiftly spread among
polio; it can only be prevented. unimmunized populations. Failure to eradicate polio throughout
Despite vigorous worldwide efforts to eradicate the disease, the world could result in as many as 200,000 new cases every
polio continues to affect children and adults in Afghanistan and year within 10 years all over the world (WHO, 2020a).
Pakistan (WHO, 2020a). Nursing consideration: Some members of the general public,
Polio has been eliminated in the United States, meaning that and even some healthcare professionals, may believe that
there is no year-round transmission of the virus in this country polio is no longer a threat. Nurses must educate healthcare
(CDC, 2019a). No cases of polio have originated in the United consumers about the very real dangers of polio that still exist,
States since 1970. Yet the virus has still been brought into the and of the importance of making sure that immunization is
country by travelers with polio; the last time this occurred was in current if traveling to areas where there is a risk of contracting
1993 (CDC, 2018c). Although cases of polio have decreased by the disease.

Vaccination recommendations
There are two types of polio vaccines: inactivated polio vaccine Adults traveling to areas of the world at high risk for polio,
(IPV) and oral polio vaccine (OPV). Oral polio vaccine is no longer working in a laboratory and handling specimens that may
administered. The last two countries to add inactivated polio contain the polio virus, or who are healthcare workers treating
vaccine to their routine immunization programs and discontinue patients who have or have had close contact with someone who
use of OPV are Mongolia and Zimbabwe (Whyte, 2019). could have polio and have never been vaccinated should receive
Children should be vaccinated with a total of four doses of IPV, three doses of IPV: first dose at any time, second dose 1 to 2
one dose each at 2 months, 4 months, 6 through 18 months old, months later, third dose 6 to 12 months after the second (CDC,
and 4 through 6 years old (CDC, 2018f). 2018f).
Children traveling to areas where polio still occurs should Adults in the preceding three groups who have had one or two
complete the series of vaccinations before international travel. doses of polio vaccine sometime in the past should receive the
Healthcare providers should be consulted regarding accelerating remaining one or two doses. Adults at increased risk of exposure
the polio vaccine regimen if the child cannot complete the to poliovirus who have previously completed a routine series of
routine series before leaving on the trip (CDC, 2018f). polio vaccine can receive one lifetime booster dose of IPV (CDC,
2018f).
Pathophysiology and transmission
The polio virus enters the human intestinal tract primarily via the person. Next, the virus moves into the cervical and mesenteric
fecal-oral route. The virus multiplies in oropharyngeal and lower lymph nodes and then into the blood stream. Only about 5%
gastrointestinal tract mucosa during the first 1 to 3 weeks of the of infected patients have nervous system involvement, which
incubation period. The virus may be secreted in saliva and feces causes the most adverse effects of the disease (Kishner, 2019).
during this time, leading to easy transmission from person to
Fortunately, most people with polio have only mild symptoms or drops to normal for 48 hours. Weakness affects lower limbs
none at all. They are unaware that they have been affected by more often that upper limbs.
the virus (Mayo Clinic, 2020f). ● Flaccid paralysis.
Nonparalytic polio (abortive polio) is the most common form of ● Sense of paresthesias in affected limbs without real sensation
infection and causes flulike symptoms that last for about 10 days. loss
Following are other signs and symptoms (Mayo Clinic, 2020f): ● Sensitivity to touch.
● Fever. ● Severe muscular pain.
● Headache. ● Paralysis that remains for days or weeks before slow recovery
● Sore throat. begins, which can take months or years. Some paralysis may
● Vomiting. be permanent.
● Fatigue. ● Urinary retention.
● Back pain or stiffness. ● Meningeal irritation.
● Neck pain or stiffness. ● Muscle atrophy.
● Pain or stiffness in the arms or legs. When the disease affects the brain stem, the respiratory muscle
● Muscle weakness or tenderness. nerves are affected, causing respiratory paralysis and producing
The incubation period from virus exposure to the paralytic symptoms of encephalitis. Other signs and symptoms of this
(neurologic) phase can last from 4 to 10 days but may be as long form of polio include the following (Kishner, 2019; Mayo Clinic,
as 4 to 5 weeks (Kishner, 2019). Paralytic polio symptoms mimic 2020f):
the less severe form of the disease for about 7 days, at which ● Facial weakness.
time more severe signs and symptoms develop (Davis, 2019; ● Diplopia.
Kishner, 2019). Following are the signs and symptoms (Davis, ● Dysphagia.
2019; Mayo Clinic, 2020f): ● Trouble chewing.
● Increasing severity of muscle aches and spasms. ● Difficulty or inability to swallow or expel salvia.
● Initially brisk reflexes progressing to absent reflexes. ● Food regurgitation through the nose.
● Muscle weakness that tends to maximize within 48 hours. No ● Dyspnea.
progression of weakness should be noted after temperature ● Abnormal respiratory rate, depth, and rhythm.
Diagnosis, treatment, and nursing considerations

Diagnosis is confirmed when polio virus is isolated from throat ● Meticulously monitoring for signs of paralysis and other
washings obtained early in the course of the disease, feces types of neurological compromise. These complications can
throughout the course of the disease, and cerebrospinal fluid occur quickly, including respiratory compromise. Emergency
(CSF) cultures in patients with CNS infection (Kishner, 2019; respiratory equipment should be maintained at the patient’s
Mayo Clinic, 2020f). bedside. Nurses must be prepared to assist in a tracheotomy
There is no cure for polio, so treatment is supportive. Analgesics at the first signs of respiratory distress. Patients are placed on
are administered to reduce pain and leg spasms. Physical mechanical ventilation to maintain adequate ventilation.
therapy may help to alleviate spasms and increase strength. ● Performing vital signs and neurologic assessments at regular
Mechanical ventilation may be necessary if respiratory muscles intervals: These patients can deteriorate rapidly, so routine
are severely affected (Mayo Clinic, 2020f). Morphine is vital signs need to be more frequent.
contraindicated for pain relief because it suppresses respiratory ● Monitoring patients for signs of fecal impaction, which can
muscle function (Comerford & Durkin, 2021). occur with dehydration and lack of intestinal activity.
● Facilitating adequate fluid and nutritional intake.
Patients remain on bed rest only until extreme discomfort ● Providing good skin care is essential, especially for patients
resolves, which may take quite some time. Patients who have who suffer from paralysis.
paralytic polio require extensive rehabilitation. Convalescence ● Using high top sneakers or a footboard to prevent foot drop.
is prolonged and patients need significant emotional support ● Placing patients on strict contact precautions: Only
(Kishner, 2019; Mayo Clinic, 2020f). nurses and other healthcare professionals who have been
Critical nursing considerations include the following issues vaccinated against polio should provide patient care.
(Davis, 2019; Kishner, 2019; Mayo Clinic, 2020f): ● Reporting all cases of polio to the public health department.

POST-POLIO SYNDROME
The majority of nurses in the US are not likely to provide care experience only minor symptoms; others develop serious
for patients afflicted with polio. However, it is possible that they muscle weakness and atrophy. The most common symptoms
will encounter people dealing with post-polio syndrome. Post- include slowly progressive muscle weakness and fatigue. This
polio syndrome (PPS) is a neurological disorder that affects acute is concerning because weakness of respiratory muscles can
paralytic polio survivors’ decades (an average of 30 to 40 years) compromise breathing. Also worrisome is that weakness in
after recovery from an initial acute attack of polio (Mayo Clinic, swallowing muscles puts patients at risk for aspirating food
2020g). PPS progresses quite slowly with periods of relative and liquids. Joint pain and generalized muscle weakness can
stability alternating with periods of decline. PPS is characterized significantly impair mobility. Even though polio is contagious, PPS
by new and progressive muscular weakness, pain, and fatigue. is not. Only a polio survivor can develop PPS (National Institute of
Although rarely life-threatening, PPS can significantly interfere Neurological Disorders and Stroke, 2020).
with a person’s ability to function independently. Some people
Incidence and etiology
The precise incidence and prevalence of PPS is unknown. It is neurons, surviving cells sprout new nerve-end terminals that
estimated that the incidence of PPS ranges from about 22% to connect with other muscle fibers. These new fibers may initially
68%. Prevalence of PPS is estimated at 28.5% of all paralytic help in recovery but, over time, the increased workload and stress
polio cases. Currently, about 1.6 million cases of PPS have been placed upon them causes a slow degeneration of neurons. Some
documented (Kedlaya, 2019). experts hypothesize that PPS is caused by the usual stressors of
Some experts believe that if polio survivors are monitored long age and weight gain (National Institute of Neurological Disorders
enough, 100% of them will develop some symptoms of PPS. Risk and Stroke, 2020).
of developing PPS is significantly higher in females and in people Nursing consideration: Research has shown that PPS can
who have sustained significant permanent impairment after having have devastating consequences for people who have survived
polio. Research has shown that PPS incidence peaks at 30 to 34 initial infection by the polio virus (Kedlaya, 2019). But not
years after acute polio (Kedlaya, 2019). all healthcare professionals may be aware of the syndrome.
The exact cause of PPS is unknown. However, several theories Nurses are obliged to educate patients, families, and
attempt to explain the syndrome. One theory involves the colleagues about PPS, its effects, and how to help patients
degeneration of individual nerve terminals in neural motor cope with the effects of the syndrome.
units. In an attempt to compensate for the loss of polio-affected
Diagnosis
Diagnosis is based on history and clinical manifestations. There patients should have their original polio diagnosis confirmed
are no laboratory tests that are specific to PPS and symptoms with an EMG study rather than simply a reported history.
vary among patients (National Institute of Neurological Disorders ● A period of partial or complete functional recovery after
and Stroke, 2020). acute paralytic poliomyelitis followed by an interval (of
Diagnostic criteria for PPS are published by the March of Dimes usually 15 or more years) of stable neurologic function.
and have been validated by a team of international experts. ● Gradual progressive and persistent new muscle weakness or
These criteria include the following (National Institute of decreased endurance, with or without generalized fatigue,
Neurological Disorders and Stroke, 2020): muscle atrophy, or muscle and joint pain: Sudden onset of
● Prior paralytic poliomyelitis with evidence of motor neuron PPS may follow a period of inactivity, trauma, or surgery.
loss: Motor neuron loss is confirmed by a history of acute Less often, symptoms associated with PPS may lead to new
paralytic polio, signs of residual weakness and atrophy of problems with breathing or swallowing.
muscles on neuromuscular exam, and signs of motor neuron ● Signs and symptoms must persist for at least 1 year. Other
loss on electromyography (EMG). On rare occasions some neurologic, medica,l or orthopedic problems must be ruled
people present with PPS symptoms who have had only subtle out as causes of symptoms.
paralytic polio symptoms with no obvious deficit. These
Treatment and nursing considerations
At this time there are no effective pharmaceutical treatments ● Exercise under the supervision of healthcare professionals
to stop or prevent deterioration or reverse the syndrome’s who have experience in PPS syndrome: Exercise must be
adverse effects. Focus is on identifying interventions that carefully prescribed and meticulously monitored, and it is
reduce symptoms and improve quality of life. Several controlled most likely to benefit muscle groups that were least affected
research studies have shown that non-fatiguing exercises may by polio. Exercise prescriptions should address the specific
improve muscle strength and reduce fatigue (National Institute of muscle groups to include or exclude the type of exercise, its
Neurological Disorders and Stroke, 2020). frequency, and its duration.
National Institutes of Health (NIH) researchers have tried treating ● Cardiopulmonary endurance training is usually more
PPS patients with high doses of prednisone. Although patients beneficial than strengthening exercises. Frequent breaks
demonstrated mild improvement, results were not statistically should be implemented with energy conservation
significant and the side effects of steroid treatment outweighed techniques. Intense resistive exercises and weightlifting
the benefits. Therefore, it was determined that steroid therapy may cause damage and can further weaken, rather than
should not be used to treat PPS (National Institute of Neurological strengthen, affected muscles.
Disorders and Stroke, 2020). ● Physical therapy may help strengthen muscles.
● Speech therapy may help to compensate for swallowing
Additional treatment options under investigation problems.
include preliminary studies that suggest that intravenous ● Pain relievers (Tylenol, Advil) may help to ease muscle and
immunoglobulin may reduce pain and improve quality of life. joint pain.
A small trial that used the anticonvulsant lamotrigine to treat Patients with PPS may benefit from joining support groups that
fatigue showed modest effects. But larger, more controlled encourage self-help strategies and positive recommendations.
studies are needed in order to validate these findings (National
Institute of Neurological Disorders and Stroke, 2020).
Recommended PPS management strategies include the
following (Mayo Clinic, 2020g; National Institute of Neurological
Disorders and Stroke, 2020):

Nursing consideration: Patients and caregivers should be PPS symptoms (National Institute of Neurological Disorders and
taught that exercise should be reduced or discontinued if it Stroke, 2020).
leads to additional weakness, fatigue, or excessive recovery
time from the effects of exercising. Muscles should not be Self-Assessment Quiz Question #2
exercised to the point of causing pain, fatigue, or weakness.
All exercise programs must be monitored by experienced When counseling patients and their families about polio, it is
healthcare professionals (National Institute of Neurological important to explain which of the following?
Disorders and Stroke, 2020). a. The polio vaccine is not recommended for anyone born after
1975.
There is no known way to prevent PPS. Polio survivors should
b. Oral polio vaccine (OPV) is recommended for children.
take steps to live a healthy lifestyle, including eating a well-
balanced, nutritional diet, getting plenty of rest, avoiding c. It is recommended that adults do not receive polio vaccine.
smoking, using prescribed assistive devices, and following a d. Children should be vaccinated with a total of four doses of
medically prescribed exercise program. Taking anti-inflammatory IPV.
medications under a physician’s supervision may help reduce
Critical thinking scenario
Amanda, a 65- year-old retired investment banker, is looking and it’s not a problem anymore anyway. I’m not going to get
forward to the birth of her first grandchild. Her son and any more vaccines at my age.” Her son explains that whooping
daughter-in-law have asked that all close family members check cough is still common in the United States. Amanda still refuses
with their healthcare providers to be sure that their pertussis to comply with his request. Her refusal has led to estrangement
(whooping cough) immunization (and all other immunizations) from her son and daughter-in-law. Amanda, however, remains
is current. They are rightfully concerned about their baby’s adamant and is not going to worry about “diseases that don’t
well-being. Amanda is insulted. “I never had whooping cough, cause problems anymore.”
PERTUSSIS VACCINATION
Pertussis, commonly known as whooping cough, is an extremely In the US, DTaP is given to infants and children to prevent
contagious respiratory tract infection. Its effects can become diphtheria, tetanus, and pertussis. They should receive five doses
serious, even deadly, especially in infants. For this reason, it is of this vaccine, usually administered at 2, 4, 6 months, 15 through
imperative that pregnant women and others who will have close 18 months, and 4 through 6 years of age. DT can be used for
contact with an infant be vaccinated against pertussis (CDC, infants and children who should not receive acellular pertussis-
2021d; Mayo Clinic, 2019e). Grandparents and other older adults containing vaccines (CDC, 2021d).
that have contact with infants can pose a particular risk and should Following are additional vaccine recommendations (CDC, 2021b;
be immunized. CDC, 2021d):
Since pertussis vaccines were introduced in the 1940s, reported ● Adolescents should receive a single dose of Tdap, preferably
cases of the disease have declined significantly from more than at 11 to 12 years of age.
100,000 annually to fewer than 10,000 by 1965. But during the ● Pregnant women should receive a single dose of Tdap
1980s, pertussis reports began to gradually increase. By 2015 (the during every pregnancy, preferably at 27 through 36 weeks’
most current year of available data), more than 20,000 cases were gestation. The rationale for receiving Tdap with every
reported throughout the United States (CDC, 2019d; CDC, 2019e; pregnancy is that antibodies to the disease decrease over
Mayo Clinic, 2020b). time; therefore, antibody levels will not remain high enough
The incidence of whooping cough is believed to be increasing for to provide adequate protection for future pregnancies.
two main reasons: The pertussis vaccine immunity received when ● Tdap is recommended only in the immediate postpartum
vaccinated as a child has decreased, leaving most teenagers and period before discharge from the hospital or birthing center
adults susceptible to the disease during an outbreak. Children are for new mothers who have never received Tdap before or
not fully immune until they have received at least three injections. whose vaccination status is unknown.
This means that infants 6 months of age and younger are at ● A dose of Tdap can be given at any time for adults who have
highest risk for contracting the disease (Harvard School of Public never received it.
Health, 2017). Nursing consideration: Some vaccines are contraindicated
Several forms of the vaccine are used to prevent diphtheria, during pregnancy; others, such as the pertussis vaccine, are
tetanus, and pertussis. Some forms are combined with vaccines to recommended during each pregnancy. Nurses must know the
prevent other diseases and thus reduce the number of injections guidelines for vaccine administration, including guidelines
received at one time. In the US, children younger than 7 years during pregnancy. This CDC resource provides information
of age receive DTaP. Older children, teens, and adults get Tdap on current recommendations: https://www.cdc.gov/vaccines/
(CDC, 2021b). schedules/index.html

Pertussis is caused by the nonmotile gram-negative Pertussis complications can be life-threatening. A number of
coccobacillus called Bordetella pertussis (B. pertussis). Pertussis complications are associated with pertussis Mayo Clinic, 2019e;
is characterized by a violent cough that becomes paroxysmal Meadows-Oliver, 2019):
and usually ends in a high-pitched inspiratory “whooping” ● Aspiration pneumonia.
sound. The disease is most severe in older adults and in infants. ● Atelectasis.
Death in children younger than 1 year of age is most often ● Coma.
caused by pneumonia and other complications of the disease ● Conjunctival hemorrhage.
(CDC, 2019d). ● Convulsions.
Pertussis is transmitted directly through inhalation of ● Detached retina.
contaminated respiratory droplets and indirectly from contact ● Emphysema.
with soiled linen and other items contaminated by respiratory ● Encephalopathy.
secretions (Mayo Clinic, 2019e; Meadows-Oliver, 2019). ● Epistaxis.
● Periorbital edema.
● Pneumonia.
● Pneumothorax.

The incubation period is about 5 to 10 days, after which the from 1 week to as long as 10 weeks (CDC, 2019d; CDC, 2019e;
bacteria enter the trachea-bronchial mucosa. Pertussis follows Mayo Clinic, 2019e).
a characteristic 6- week course that includes three stages: Sometimes coughing is so severe and prolonged that the
catarrhal, paroxysmal, and convalescent. Each of these stages following clinical manifestations occur (CDC, 2019d; CDC,
lasts about 2 weeks. The disease is most communicable 2019e; Mayo Clinic, 2019e):
just before the catarrhal stage to 3 weeks after onset of the ● Atelectasis.
paroxysms or until coughing has stopped (CDC, 2019d; Mayo ● Bruised or cracked ribs.
Clinic, 2019e). ● Conjunctival hemorrhage.
Stage 1: Catarrhal stage: During the first stage of pertussis, ● Detached retina that may lead to blindness.
symptoms are generally mild and resemble a common cold that ● Epistaxis (nosebleed).
lasts from 1 to 2 weeks (CDC, 2019d; CDC, 2019e; Mayo Clinic, ● Hemorrhage of the eye’s anterior chamber.
2019e). Signs and symptoms of the catarrhal stage, during which ● Increased venous pressure.
the disease is highly communicable, include the following (CDC, ● Inguinal, abdominal, or umbilical hernia.
2019d; CDC, 2019e; Mayo Clinic, 2019e): ● Choking on the thick mucus, which can lead to nausea and
● Anorexia. vomiting. Periorbital edema.
● Dry, hacking cough that is often worse at night. ● Pneumonia.
● Infected conjunctiva. ● Rectal prolapse.
● Low-grade fever. ● Respiratory distress.
● Nasal congestion. ● Seizures.
● Red, watery eyes. ● Vomiting.
● Sneezing. Stage III: Convalescent stage: The convalescent stage can last
Stage II: Paroxysmal stage. After about 7 to 14 days, the from 2 weeks to several months. Paroxysmal coughing gradually
paroxysmal stage begins. This stage is characterized by the subsides. However, such coughing may reoccur with respiratory
accumulation of thick mucus that accumulates in the airways, infections. For months afterward even slight respiratory
leading to uncontrollable coughing, and lasts for2o to 4 weeks infections may cause the patient to develop paroxysmal
or longer. The paroxysmal cough is characteristic of the disease coughing. In some patients the convalescent stage may last for
and ends in a loud, inspiratory whoop sound. This stage can last weeks, months, or even years (CDC, 2019d; CDC, 2019e; Mayo
Clinic, 2019e).
Diagnosis
Classic clinical manifestations and history suggest a diagnosis of ● White blood cell count: Although not specific for pertussis,
pertussis. The following tests can confirm the diagnosis (CDC, an elevated white blood cell count suggests infection or
2019d; CDC, 2019e; Mayo Clinic, 2019e): inflammation.
● Nose or throat culture: A nose, throat, or suction sample is ● Chest X-ray: A chest X-ray may be performed to assess for
obtained and cultured. pneumonia or fluid in the lungs.
Treatment
Treatment consists of vigorous supportive therapy, including ● Because codeine can cause nausea and constipation,
fluid and electrolyte replacement, especially for infants, who are patients should be observed for both. Patients should eat
generally hospitalized. Older children and adults usually receive small frequent meals to facilitate nutritional intake in the
treatment at home. Following are additional treatment measures presence of anorexia, nausea, and paroxysmal coughing.
(CDC, 2019d; CDC, 2019e; Mayo Clinic, 2019e; Meadows- Fluids and an adequate diet can help reduce constipation.
Oliver, 2019): If constipation becomes significant, laxatives may be
● Administrating antipyretics. administered.
● Administrating antibiotics to prevent disease progression and ● Infants may need suctioning, which should be gently
treat secondary infections. performed. During suctioning, patients must be carefully
● Administrating mild sedation and codeine to reduce monitored for respiratory distress because suctioning
coughing. removes oxygen while removing secretions.
● Facilitating bed rest. ● Change soiled linens as often as needed and as soon as
● Implementing a quiet, restful environment. possible after contamination.
● Providing adequate nutrition and facilitating fluid intake. ● Waste containers for the disposal of tissues and other items
● Implementing gentle suctioning of infants as necessary. contaminated by respiratory droplets should be within easy
● Providing oxygen therapy as needed. reach and emptied often.
● Empty suction bottles at least once a shift or more often if
Nursing concerns: A number of nursing concerns are necessary to decrease exposure to contaminated contents.
associated with pertussis. Although most older children ● Report all pertussis cases to public officials as soon as
and adults are treated at home, they (and their families) possible.
must know how to facilitate recovery. Infants are usually Family members, work colleagues, friends, day care personnel,
hospitalized (Mayo Clinic, 2019e; Meadows-Oliver, 2019). and others who have had close contact with the patient should
have their immune status evaluated (CDC, 2019d; CDC, 2019e;
● Droplet precautions (surgical masks only) should be in place Mayo Clinic, 2019e).
for 5 to 7 days after initiating antibiotic therapy. The wearing
of masks for family/household members depends on the The parents of infants with whooping cough need emotional
likelihood of transmission, the immune status of household support because infants generally become quite ill. Nurses
members, and the health of people in close contact with the should ensure that parents receive accurate information about
patient. the pertussis vaccine and other available vaccines to stop the
● The environment should be as quiet and calm as possible. spread of vaccine-preventable diseases (Meadows-Oliver, 2019).
Stressors should be reduced as much as possible. These
interventions should help to reduce coughing.
DIPHTHERIA
Diphtheria is an acute toxin-mediated upper respiratory infection cause disease, which is usually mild (Demirci, 2019). Once a
caused by Corynebacterium diphtheria. Nontoxic strains also major cause of illness and death in children, diphtheria was

responsible for 15,520 deaths (out of 206,000 reported cases) Before the development of effective treatment, diphtheria was
in 1921. Fortunately, thanks to successful vaccination initiatives fatal in up to 50% of reported cases. Currently, the overall case-
that began in the 1920s, the incidence of diphtheria decreased fatality rate for diphtheria is 5% to 10%. Higher fatality rates of
rapidly in the US and other countries that implemented up to 20% are reported in children younger than 5 years of age
vaccination programs. However, diphtheria continues to cause and in adults over the age of 40 (CDC, 2020c).
disease globally (CDC, 2020c).
Vaccination
Four vaccines provide protection against diphtheria: ● 2 months.
1. The DTaP vaccine protects children from diphtheria, tetanus, ● 4 months.
and whooping cough. ● 6 months.
2. The DT vaccine protects young children from diphtheria and ● 15 through 18 months.
tetanus. ● 4 through 6 years.
3. The Tdap vaccine protects preteens, teens, and adults from Preteens and teens (ages 7 through 18) should receive one
tetanus, diphtheria, and whooping cough. booster shot of the Tdap at age 11 or 12 as part of their routine
4. The Td vaccine protects preteens, teens, and adults from vaccination schedule. Adults age 19 and older need one booster
tetanus and diphtheria. shot of the Td vaccine every 10 years as part of routine vaccine
The vaccine options used to prevent diphtheria include schedule. Pregnant women need one booster shot of the Tdap
protection against tetanus and may include pertussis as well. vaccine during the third trimester of each pregnancy (HHS.gov.,
Children should receive five doses of the diphtheria, tetanus 2020a).
toxoids, and acellular pertussis (DTaP) vaccine, one dose at each
of the following ages (HHS.gov., 2020a):
Transmission and pathophysiology
Diphtheria is transmitted through intimate contact, contact system. Even with treatment in these stages, diphtheria can be
with airborne respiratory droplets, and by direct contact with fatal, particularly in children (Mayo Clinic, 2020a). In more than
contaminated articles and the environment. Asymptomatic 90% of patients, the tonsils or the pharynx are the primary areas
carriers, currently sick people, and convalescing patients may affected by diphtheria infection. The nose and larynx are the
transmit the disease. Infected people who have not been next most common sites (Demirci, 2019).
treated may spread the disease for up to 6 weeks even if they The organisms that cause the disease generally stay in the
are asymptomatic. Diphtheria is very rare in the US and other superficial layers of skin lesions or respiratory mucosa causing
developed countries thanks to widespread vaccination efforts, local inflammatory reactions. The major virulence of the
but the disease is still common in countries where vaccination diphtheria pathogens is their ability to produce a potent
rates are low (Mayo Clinic, 2020a). exotoxin that interferes with protein synthesis, causing necrosis
Diphtheria can be treated with medication. In its advanced of local tissues and forming false membranes on mucosal
stages, diphtheria can damage the heart, kidneys, and nervous surfaces (Demirci, 2019).
The incubation period for diphtheria is from 2 to 5 days. There ● Paralysis of the palate muscles making it difficult to swallow.
are several forms of the disease, the most common being ● Development of lymphadenopathy: Fever and rapid pulse
tonsillar and pharyngeal diphtheria. Attempts to remove may also develop.
the membrane that develops with the disease usually cause Neurological complications correspond to the extent of the
bleeding, which is characteristic of the disease (Demirci, 2019). primary infection and include the following (CDC, 2020c;
This form of diphtheria usually begins with a sore throat. Fever, Demirci, 2019; Mayo Clinic, 2020a):
if it occurs, is usually less than 102 °F. Patients may experience ● Paralysis of the soft palate.
general malaise, anorexia, and headache, but these are not ● Weakness of facial, laryngeal, and pharyngeal nerves, which
prominent characteristics of the disease (CDC, 2020c; Demirci, makes it difficult to swallow, thereby increasing the risk of
2019; Mayo Clinic, 2020a). aspiration. Such weakness also makes the voice sound harsh,
More characteristic symptoms include the following clinical with an accompanying nasal quality.
manifestations (CDC, 2020c; Demirci, 2019; Mayo Clinic, 2020a): ● Development of cranial neuropathies during the fifth week
● Formation of a patchy, thick, grayish-green membrane over of infection: This can cause blurred vision, strabismus, and
the mucus membranes of the pharyngeal walls, tonsils, uvula, compromised visual accommodation.
and soft palate: The membrane may extend to the larynx ● Development of motor function deficit and diminished deep
and trachea. This can cause airway obstruction and even tendon reflexes.
suffocation. Paralysis of the diaphragm can occur, seriously compromising
● Edema of the tissues of the throat and neck: Edema of the respiratory status and leading to respiratory arrest (CDC, 2020c;
neck may become so severe that a characteristic “bull neck” Demirci, 2019; Mayo Clinic, 2020a).
appearance develops. Patients may throw back their heads to
relieve pressure on the throat and larynx. Evidence-based practice! Research has shown that the extent
● Development of edema associated with pharyngeal of the disease correlates with significant prostration, presence
diphtheria obliterates the angle of the jaw, the borders of the of bull neck, and airway compromise (CDC, 2020c; Demirci,
sternocleidomastoid muscle, and the medical border of the 2019; Mayo Clinic, 2020a.)
clavicles.
Laryngeal and nasal diphtheria
Following are signs and symptoms of laryngeal and nasal ● Whitish-gray membrane over nasal septum.
diphtheria, which occur most often in infants (CDC, 2020c; ● Respiratory tract obstruction.
Demirci, 2019; Mayo Clinic, 2020a): ● Acute inflammation of the mucus membranes of the nasal
● Low-grade fever. cavities.
● Stridor. ● Foul oral odor.
● Barking cough.
● Hoarseness that can progress to loss of voice.

Cutaneous diphtheria
Cutaneous (affecting the skin) diphtheria may occur at one or Clinical manifestations include pain, erythema, and exudate
multiple sites. It is generally localized to areas of the skin that at the infection site. Ulceration develops. Lesions have
have sustained mild trauma (CDC, 2020c; Demirci, 2019; Mayo clearly defined borders with a brownish-gray membrane. The
Clinic, 2020a). extremities are the most likely sites of infection. Cutaneous
diphtheria may linger for weeks to months (CDC, 2020c; Demirci,
2019; Mayo Clinic, 2020a).
Complications
A number of complications are associated with diphtheria, ● Myocarditis.
including the following (CDC, 2020c; Demirci, 2019; Mayo Clinic, ● Neurologic compromise.
2020a): ● Paralysis.
● Cardiac compromise. ● Renal involvement such as nephritis.
● Gastritis. ● Thrombocytopenia.
● Hepatic compromise such as hepatitis.
Diagnosis
Diagnosis is made based on the characteristic membrane and
a throat culture or other suspected lesions for Corynebacterium
diphtheria (CDC, 2020c; Demirci, 2019; Mayo Clinic, 2020a):
People who have probable or confirmed diphtheria are eligible ● Cardiac monitoring.
to receive diphtheria antitoxin (DAT), which is the mainstay of ● Respiratory support measures as needed.
treatment, either intramuscularly or intravenously. Although not ● Bed rest may be initiated for 2 to 3 weeks.
licensed by FDA, DAT is authorized for distribution to physicians ● Keeping the patient hydrated.
as an investigational new drug (CDC, 2020d). ● Isolation with contact and droplet precautions until obtaining
DAT neutralizes free toxins only. It is not recommended for two to three consecutive negative nasopharyngeal cultures at
asymptomatic carriers. Asymptomatic carriers receive the least 2 weeks after completing drug therapy.
following interventions (CDC, 2020d; Demirci, 2019): ● Maintaining the environment at high humidity, especially for
● A 7-to 10-day course of prophylactic antimicrobial therapy. laryngeal diphtheria patients.
● An age-appropriate form of diphtheria vaccine if the person ● Reporting all diphtheria cases to the public health
has not received a booster within 1 year. department.
● Placement in respiratory or contact isolation (for cutaneous Patients must be monitored for signs of shock, which can
findings) until at least two subsequent cultures, taken 24 develop abruptly. They must be constantly monitored for
hours apart after therapy has stopped, are negative. respiratory distress, and equipment for immediate life support
● Repeat cultures are taken at a minimum of 2 weeks after such as intubation and tracheotomy must be kept near the
therapy is complete. If results are positive, a 10-day course of bedside (Demirci, 2019).
oral erythromycin is initiated. The best practice is prevention through proper immunization.
In addition to DAT, symptomatic patients with diagnosed Nurses should teach patients of all ages about the need, not
diphtheria receive the following treatment interventions (Demirci, only for age- appropriate childhood immunization, but also for
2019): adolescent and adult immunization. Protective immunity does
● Antibiotic therapy (penicillin, erythromycin) to eliminate the not last more than 10 years after the last vaccination. Therefore,
organisms from the upper respiratory sites and other affected people should receive a booster dose every 10 years (HHS.gov.,
areas. 2020a).
INFLUENZA
Breakthrough by Du Pont: A Drug that Blocks Viruses. The preceding excerpt from the February 10, 1967, issue of
Only last year, when a model of the flu virus appeared Life Magazine shows how the quest for agents to combat
on Life’s cover, there existed no pill or capsule a doctor influenza has progressed. In 1967, Symmetrel was considered a
could prescribe to combat it, or, for that matter, any other breakthrough drug in the fight against the disease. Today, the
virus. But a fascinating new drug called Symmetrel is just generic form of Symmetrel, amantadine, is used as an anti-
going on the market and will forever change the situation. Parkinson agent. For the past several years, CDC has advised
Because of it, the flu virus – at least the dreaded A2 variety physicians not to use amantadine to treat or prevent influenza
popularly known as Asian flu – has lost its supreme chemical because it has not shown to effectively prevent most types
invulnerability, offering hope that other virus enemies will of influenza virus (Comerford & Durkin, 2021; Ratini, 2020). In
1967, the drug was one of the starting points for antiviral drug
soon lose theirs. (Rosenfeld, 1967, pp. 60A-61A)
investigation and is still prescribed by some physicians as an
antiviral agent to treat influenza today.
Vaccination
The most effective way to treat influenza, or the “flu” as it is ● Illinois.
commonly known, is to prevent it through an annual vaccination ● Maine.
for the specific strains predicted to cause the disease in a given ● Maryland.
year. Each year the influenza vaccine is unique to the anticipated ● Massachusetts.
strains and should be administered starting in October. ● Nebraska.
As of October 2020, an estimated 33% of states require ● Nevada.
hospitals to offer flu shots or track their vaccination statuses ● New Hampshire.
to help boost flu vaccination rates in healthcare settings. The ● New Jersey.
following 17 states mandate that hospitals offer flu vaccines or ● New York.
report employees’ vaccination status (Bean, 2020a): ● Oklahoma.
● California. ● Oregon.
● Colorado. ● Rhode Island.
● Georgia. ● South Carolina.
● Tennessee.

CDC recommends that workers in healthcare settings get annual nursing home personnel, and teachers and staff of day cares
flu vaccine. The issue of mandating the flu vaccine for healthcare and schools are at higher risk and should be immunized early in
workers by their employers is controversial. Appropriate the flu season. Mandatory programs such as the Johns Hopkins
exemptions are typically respected, but refusing to vaccinate Health System’s 2020-2021 Mandatory Flu Vaccination program
may have other consequences. CDC also recommends that include the following information: the mandatory flu vaccination
employees be provided with the opportunity to receive an campaign began in September 2020; every staff and faculty
exemption under certain medical and religious circumstances member, resident, postdoctoral fellow, medical student, and
(CDC, 2020j; Williamson, 2019). volunteer who works with patients or works in a patient care area
There are pros and cons to mandatory vaccination. Some pros or building must receive a flu vaccination; deadline to request a
include the following (Williamson, 2019): medical or religious exception is Tuesday, November 10, 2020
● Lower rates of influenza among healthcare professionals. (Johns Hopkins Health System, 2020).
● Fewer employee absences related to flu.
● Lower patient mortality rates. Nursing consideration: Note that there is a mechanism for
● Financial benefits to the healthcare facility because of fewer requesting exception to vaccination. Healthcare consumers
absences and lower mortality rates. should consult their respective state laws to find out how to
apply for exemptions. Healthcare workers who decline the
Cons of requiring flu shots include the following (Williamson, immunization may be transferred to areas where there is
2019): limited contact with patients.
● Time needed to identify those who have exemptions and
make arrangements for such exemptions. The influenza vaccine contains three or four virus strains and
● Concern of employees who may have had a bad experience changes annually, based on predictions of predominant strains
after receiving a prior flu shot or other vaccines. that are expected to dominate the upcoming flu season. It is
● Time needed to review legal and ethical mandates regarding recommended that people age 6 months and older receive
vaccination and what exemptions are currently in place. age-appropriate forms of the influenza vaccine annually unless
Some healthcare facilities have established a mandatory flu medically contraindicated (Blair, 2018; Mayo Clinic, 2020c).
vaccination program. First responders, military personnel,
Influenza, or the grippe, is an extremely contagious acute those who suffer from chronic diseases (Blair, 2018; Mayo Clinic,
viral infection of the respiratory tract. Influenza is caused by 2020c).
three different types of virus families and occurs sporadically Influenza is transmitted directly through inhalation of infected
throughout the year or in epidemics, usually during the colder respiratory droplets and indirectly via contact with an object
months. The disease is usually self-limiting (Blair, 2018; Mayo contaminated by respiratory secretions, such as a drinking glass
Clinic, 2020c). or article of clothing (Blair, 2018; Mayo Clinic, 2020c).
People of all ages contract influenza, but the incidence is highest Between 5% and 20% of the US population contracts influenza
in school-age children. Influenza is most severe and most often annually. Up to 49,000 deaths in a single year have been
leads to complications in young children, older adults, and reported (Blair, 2018).
Risk factors
Certain factors increase a person’s risk for contracting influenza having HIV/AIDS, or taking antirejection drugs or
or developing complications, including the following (American corticosteroids are at higher risk for developing influenza and
Lung Association, 2020; Blair, 2018; Mayo Clinic, 2020c): for suffering from its complications.
● Age: The people most often affected by seasonal influenza ● Environment/living conditions: People who live in close
are young children under the age of 5 and people over the contact with others, such as residents in long-term care
age of 65. Occasionally, strains of the virus may target other facilities or soldiers in barracks, are at higher risk for
groups. For example, the H1N1 virus responsible for the contracting influenza.
2009 pandemic targeted teenagers and young adults. ● Occupations: Healthcare workers and people who work with
● Chronic illnesses: Chronic health problems – such as children (day care personnel, teachers) are at a higher risk of
cardiovascular disease, diabetes, or COPD– increase the risk contracting influenza.
of influenza complications. ● Pregnancy: Pregnant women are more likely to develop
● Compromised immune system: People whose immune influenza complications, especially in their second and third
systems are compromised because of cancer treatment, trimesters and up to 2 weeks postpartum.
Complications
Influenza can cause a number of complications, including the ● Exacerbation of chronic obstructive pulmonary disease
following (American Lung Association, 2020; Blair, 2018; Mayo (COPD). Myocarditis (rare).
Clinic, 2020c): ● Pericarditis (rare).
● Bronchitis. ● Pneumonia (the most common complication). Reye’s
● Ear infections. syndrome.
● Encephalitis. ● Sinus infections.
Pathophysiology
The influenza virus causes disease by invading the epithelium ● The influenza virus contains RNA that is covered and protected
of the respiratory tract where it causes inflammation and by a layer of protein. The RNA carries the code for viral
desquamation. The virus is classified into one of three categories replication. The virus’s genetic material has an astonishing
(CDC, 2019k; CDC, 2020f; CDC, 2020g): ability to mutate, leading to various new viral strains.
1. Type A: most common type of influenza virus: It occurs ● The virus (like all viruses) needs a host cell to replicate its
every year with various new serotypes that cause epidemics genetic material and protein. After attaching itself to the host
every 3 years. cell, the virus replicates into new virus components that invade
2. Type B: occurs annually and causes epidemics only every 4 additional healthy cells.
to 6 years. ● The virus invades the host cells, destroying them. This
3. Type C: is endemic and causes only sporadic outbreaks. destruction interferes with normal respiratory defense
The influenza virus multiplies within the respiratory system along mechanisms, leaving the patient susceptible to secondary
the following track (CDC, 2019k): bacterial infections.

After a 1 to 4 day incubation period, there is an abrupt onset of ● Nasal congestion.
the following symptoms (CDC, 2019k; CDC, 2020f; Mayo Clinic, ● Rhinorrhea.
2020c): ● Rhinitis.
● Chills. ● Sore throat.
● Conjunctivitis. Acute symptoms generally diminish within 3 to 5 days, but cough,
● Fatigue. fatigue, and weakness may persist for weeks, especially in older
● Fever above 104 °F. adults. Fever is generally higher in children than in adults, and
● Headache. croup and cervical adenopathy (lymphadenopathy of the cervical
● Hoarseness. lymph nodes) are commonly found in children with influenza
● Laryngitis. (Mayo Clinic, 2020c).
● Malaise.
● Myalgia (especially predominant in the limbs and in the back).
Diagnosis
Generally, diagnosis requires only a patient history, physical nasopharyngeal samples or throat samples. The rapid influenza
assessment, and the presence of signs and symptoms. The antigen test can be performed in the office and can show results
diagnosis may be confirmed by isolating the virus from in 15 to 30 minutes. Chest X-ray in older adults and other high-risk
pharyngeal or nasal secretions or by identifying viral antigens in patients is recommended to rule out pneumonia. Additionally,
nasopharyngeal cells using a fluorescent antibody test, known rapid diagnostic tests that have a high degree of specificity but
as the enzyme-linked immunosorbent assay, or ELISA. The moderate sensitivity are being used more often as part of the
standard for diagnosing influenza A and B is a viral culture of diagnostic process (Mayo Clinic, 2020c; Pagana & Pagana, 2018).
Because influenza is a virus, it cannot be treated with antibiotics Side effects include nausea and vomiting, which may be
that are often requested by patients. Treating uncomplicated decreased if the medications are taken with food. It is important
influenza consists largely of supportive measures such as the to note that most circulating strains of influenza have become
following (CDC, 2020h; Mayo Clinic, 2020c). resistant to amantadine and rimantadine (Flumadine). These older
● Over-the-counter age-appropriate medicines to reduce fever antiviral drugs are no longer recommended (Mayo Clinic, 2020c).
and relieve aches and pains, such as acetaminophen (Tylenol), Because most uncomplicated cases of influenza do not require
aspirin, or ibuprofen (Advil, Motrin IB). hospitalization, nurses should teach patients and family members
● Cough medicines (antitussives) to relieve nonproductive about the supportive measures described above. They should also
coughing. advise that friends and family who do not live in the home with the
● Rest and sleep to help the immune system combat the patient should avoid visits to prevent spreading the disease and to
infection. protect the patient from acquiring additional infections from such
● Increasing fluid intake to help prevent dehydration and reduce visitors (CDC, 2020g; Mayo Clinic, 2020c).
fever. Patients should avoid fluids with caffeine, which may
make it difficult to sleep. In addition, healthcare professionals should encourage patients
and family members to wash their hands frequently, especially
Nursing consideration: Nurses must remind parents and other after touching potentially contaminated articles such as
caregivers that children and teenagers should not be given telephones, bedclothes, and tissues (Blair, 2018). Healthcare
aspirin. Research has shown that aspirin increases the risk for professionals should teach patients and their family members to
Reye’s syndrome in these populations (Comerford & Durkin, recognize the signs and symptoms of complications and what
2021). action to take if they occur.
Following are recommendations for influenza vaccination (Blair,
Persons with a severe infection or who are at higher risk for 2018; CDC, 2020g; Mayo Clinic, 2020c):
complications may be prescribed an antiviral drug. Such drugs ● People 6 months of age and older should receive an annual
can include oseltamivir (Tamiflu), zanamivir (Relenza), peramivir flu vaccine.
(Rapivab), and baloxavir (Xofluza; Mayo Clinic, 2020c). ● People at high risk for serious complications of influenza –
These kinds of drugs may reduce the length of illness by a day such as young children, people older than 65, individuals
or so and help to prevent serious complications. Oseltamivir is with chronic health conditions, and pregnant women –
an oral medication. Zanamivir is inhaled via inhaler, but zanamivir should receive an annual flu vaccine.
should not be used by anyone with chronic respiratory problems ● Those who care for children younger than 6 months of age
such as asthma or lung diseases (Mayo Clinic, 2020c). should be vaccinated because these infants are at high risk
for serious forms of the disease. Transmission of the disease
from unvaccinated people to children is a significant risk.
Prevention
The best preventive strategy against influenza is appropriate season, individuals should avoid crowds as much as possible to
vaccination. But not everyone vaccinated people come into reduce their chances of infection (Mayo Clinic, 2020c).
contact with has received the influenza immunization; therefore,
good hygiene measures should be implemented to help reduce Self-Assessment Quiz Question #3
the spread of influenza and other communicable diseases.
Frequent, thorough handwashing has proven to be the best way What should be done if a patient is an asymptomatic carrier of
to prevent the transmission of many communicable diseases. diphtheria?
Individuals should wash their hands vigorously for at least 15 a. Administer diphtheria antitoxin (DAT).
seconds. If soap and water are not available, they should use
b. Place in respiratory or contact isolation.
an alcohol- based hand sanitizer. Sick people should cover their
mouths and noses with a tissue, dispose of contaminated tissues c. Initiate a 5-day course of antimicrobial therapy.
in a covered trash container, and wash their hands afterward with d. Encourage aerobic exercise three times per day.
soap and water or alcohol-based hand sanitizers. During peak flu

MEASLES (RUBEOLA)
Outbreaks of measles continue to be a worldwide concern. Outbreaks of measles can be especially deadly in countries
WHO provides the following relevant statistics pertaining to experiencing or recovering from a natural disaster or conflict.
measles Damage to health services and health infrastructure interferes
(WHO, 2019): with routine immunization. Overcrowding in residential camps
● In 2019 in Europe, there was a record number of both significantly increases infection risk (WHO, 2019).
people sickened by measles and those who chose to be
immunized. In 2018, there were more than 140,000 measles Figure 2: Measles rash
deaths globally, primarily among children under the age of
5. Measles vaccination resulted in a 73% drop in measles
deaths between 2000 and 2018 globally. In 2018, an
estimated 86% of the world’s children received one dose
of measles vaccine by their first birthday, compared to 72%
in 2000. Between 2000 and 2018, measles vaccination
prevented an estimated 23.2 million deaths, making measles
vaccination one of the most effective health initiatives in
public health.
● Before the initiation of measles vaccine in 1963 and
widespread vaccination, major epidemics occurred
approximately every 2 to 3 years, and measles caused an
estimated 2.6 million deaths every year.
Unvaccinated young children are at highest risk of measles, its
complications, and death. Unvaccinated pregnant women are also
at significant risk. Measles is still common in many developing
countries, especially in parts of Africa and Asia. More than 95% of
deaths caused by measles occur in countries with low per capita
incomes and weak health infrastructures (WHO, 2019).
Goodson, J. (2014). https://phil.cdc.gov/details.aspx?pid=19434
Vaccination
Vaccination is recommended for the prevention and of measles. ● Healthcare professionals should monitor patients for signs
The vaccine typically is administered as MMR (measles, mumps, of anaphylaxis for 30 minutes after vaccination. Patients who
and rubella). Guidelines (as of this writing) include the following are immunocompromised – such as those with untreated
important factors (CDC, 2019i; CDC, 2020j; CDC, 2020k; tuberculosis, immune deficiencies, leukemia, or lymphoma,
Meadows-Oliver, 2019): or who are receiving immunosuppressants – should not
● Measles vaccine is usually administered to children between receive the vaccine.
12 and 15 months, with a second dose of measles vaccine ● Vaccination should be delayed after administration of blood
recommended between ages 4 and 6. In high-risk areas, the products or immune globulin. Such products may contain
vaccine should be given at 12 months. measles antibodies that can neutralize the vaccine. The
● During an epidemic, infants as young as 6 months may length of time to wait before administering a measles vaccine
receive the vaccine, although doses given before 12 months to these patients can vary significantly based on the type of
of age should not be counted toward the recommended two blood product or immune globulin administered.
doses. These children should be reimmunized at the age of ● Side effects of the vaccine include transient skin rashes,
15 months, with the second dose given between 4 and 6 malaise, arthralgia, and fever up to 2 weeks after receiving
years of age. the vaccine. If discomfort and swelling at the injection
● It should be determined, whenever possible, if patients have site occur, healthcare professionals should apply cold
any allergies, especially allergies to neomycin; each dose compresses.
contains a small amount of the drug. Patients who are allergic
to eggs may receive the vaccine because it has not been Evidence-based practice! Research has shown that measles is
proven to aggravate an egg allergy. becoming more prevalent in adolescents and adults. Therefore,
● Pregnant females should not receive the measles vaccine it is important that nurses encourage adolescents and adults to
because it contains live attenuated strains of the measles have their immunity status evaluated (CDC, 2020k).
virus. Females should not become pregnant for at least 4
weeks after receiving the vaccine.
Etiology and transmission
Measles (rubeola) is an acute, extremely contagious disease and 1,000 people developed chronic disability from acute
caused by the paramyxovirus. It is one of the most common, encephalitis (CDC, 2020j).
as well as one of the most serious, communicable childhood Measles is transmitted by direct contact with infected respiratory
diseases. Humans are the only natural hosts of the measles droplets or by contact with items contaminated by infected
virus. Measles is also one of the world’s most contagious respiratory droplets. It is spread by coughing and sneezing, close
diseases. In 2000, measles was declared eliminated from the US. personal contact, or direct contact with infected nasal or throat
Nevertheless, measles cases and outbreaks still occur every year secretions. The virus’s portal of entry is the upper respiratory
in the US because measles is still commonly transmitted in many tract. In temperate climate zones, incidence is highest in late
parts of the world, including countries in Europe, the Middle winter and early spring (CDC, 2020j; WHO, 2019).
East, Asia, the Americas, and Africa. The annual number of cases
has ranged from a low of 37 in 2004 to a high of 1,282 in 2019 The measles virus remains active and contagious in the air or
(CDC, 2020j). Europe saw a fourfold increase in measles cases in on infected surfaces for up to 2 hours. It can be transmitted by
2017 compared to 2016 (WHO, 2018a). an infected person from 4 days before the onset of the rash
to 4 days after the rash erupts. It is very likely that susceptible
It is possible that, on average, 3 million to 4 million people persons with close contact to a measles patient will develop the
have been infected annually, but most cases were not reported. disease. (CDC, 2020j; WHO, 2019).
Of the reported cases, about 48,000 people were hospitalized

Complications
Measles can cause serious complications, such as the following ● Otis media.
(CDC, 2020j; Meadows-Oliver, 2019; WHO, 2019): ● Pneumonia.
● Appendicitis. ● Diarrhea.
● Cervical adenitis. ● Secondary bacterial infections.
● Encephalitis. ● Autoimmune reactions.
● Laryngitis. ● Seizures.
● Mastoiditis.
After an incubation period of between 8 and 14 days, symptoms At the conclusion of the prodromal period, Koplik spots, which
begin. The greatest communicability takes place during the are the primary characteristic of rubeola, appear. These are
prodromal phase, about 11 days after patients are exposed to grayish-white or bluish-white tiny spots surrounded by a red
the virus. The prodromal phase lasts from 2 to 5 days, and signs halo. Koplik spots appear on the oral mucosa and sometimes
and symptoms, including the following, may be mistaken for a bleed (CDC, 2020j; Meadows-Oliver, 2019).
severe cold or flu (Meadows-Oliver, 2019): One to 2 days after the onset of Koplik spots, a maculopapular
● Fever. rash appears at the hairline, behind the ears, and over the
● Lethargy. neck and cheeks. The rash then spreads rapidly over the entire
● Photophobia. face, neck, eyelids, arms, chest, back, abdomen, and thighs.
● Malaise. Within 2 to 3 days, the rash reaches the feet. It then begins to
● Anorexia. fade in the same time sequence in which it appeared, leaving
● Conjunctivitis. a brownish discoloration, which disappears within 7 to 10 days.
● Coryza. Approximately 5 days after the rash appears, other symptoms
● Hoarseness. disappear and the disease is no longer communicable (CDC,
● Hacking cough. 2020j; Meadows-Oliver, 2019).
Diagnosis
Diagnosis of measles is generally made by evaluating measles infection. Both a serum sample and a throat swab (or
presenting clinical manifestations, particularly the appearance nasopharyngeal swab) from patients suspected to have measles
of the characteristic Koplik spots. Laboratory confirmation is should be obtained at first contact. Urine samples may also
now deemed essential for all sporadic cases of measles and contain virus, and collecting both respiratory and urine samples
all measles outbreaks. Detection of measles- specific IgM can increase the likelihood of detecting measles virus (CDC,
antibody and measles RNA by real-time polymerase chain 2020j; Pagana & Pagana, 2018).
reaction (RT-PCR) are the most common methods for confirming
Treatment and nursing consideration
Treatment focuses on relieving symptoms and monitoring for ● Report all cases of measles to the public health department.
possible complications. The following are common supportive ● Sedation may be medically prescribed if necessary. Teach
interventions (CDC, 2020j; Meadows-Oliver, 2019; WHO, 2019): patients and caregivers to recognize signs and symptoms of
● Encourage bed rest. impending complications and to seek immediate medical
● Maintain a calm, quiet environment. help if they occur.
● Keep the room dark to reduce the discomfort of
photophobia. Self-Assessment Quiz Question #4
● Keep the room comfortably warm and use a vaporizer to
increase humidity and decrease respiratory irritation. When counseling parents whose children have measles, the
● Administer over-the-counter, age-appropriate medicines such nurse should tell them all of the following EXCEPT:
as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin IB) to a. Outbreaks of measles still occur in the US.
reduce fever and relieve aches and pains. Do not give aspirin b. Unvaccinated young children and unvaccinated pregnant
to children or teenagers because of the risk for developing women are at highest risk for complications.
Reye’s syndrome. c. An infected person can transmit the disease from 1 day
● Offer fluids frequently. before onset of rash to 14 days after the rash erupts.
● Keep unvaccinated family members away from the patient. d. Treatment focuses on relieving symptoms and monitoring
Prevent visitors from entering the patient’s environment to for complications.
avoid transmitting the disease.
MUMPS
Mumps (also referred to as infectious or epidemic par otitis) is in the late 1960s. However, mumps outbreaks still occur and
an acute viral disease that causes a painful enlargement of the the number of cases has increased in recent years. Outbreaks
parotid glands. The parotid glands are one of three pairs of typically affect people who are not vaccinated and occur in
salivary glands located below and in front of the ears. Mumps settings where close contact is common, such as schools and
was quite common in the US until the mumps vaccination college campuses (Mayo Clinic, 2020d).
became part of routine childhood immunization programs
Vaccination
The mumps vaccine was licensed in 1967. Two vaccines can Adults who should get the mumps vaccine include those who
prevent mumps: the MMR vaccine, which provides protection did not receive the vaccine in childhood and those age 18
from measles, mumps, and rubella; and the MMRV vaccine, and older born after 1956 who have not had mumps. These
which protects from mumps, measles, rubella, and varicella. adults need at least one dose of mumps vaccine. Healthcare
Two doses of the vaccine are recommended. The first dose is professionals who have not had mumps need two doses of the
administered at 12 to 15 months of age, and the second dose at mumps vaccine (HHs.gov., 2020d).
4 to 6 years of age (as long as it is 28 days after the first dose). People should not receive the mumps vaccine if they have had
Children ages 1 through 12 can get the MMRV vaccine, which a life-threatening reaction to a dose of the mumps vaccine or to
is a combination vaccine that also protects against measles, any ingredient in the vaccine, or if they are pregnant (HHS.gov.,
rubella, and varicella (HHS.gov., 2020d). 2020d).

The patients’ healthcare providers should be informed, before The MMR vaccine is quite effective. However, immunity against
vaccination, if they (HHS.gov., 2020d): mumps is not complete. Two doses of MMR are 88% effective at
● Have HIV/AIDS. protecting against the disease. One dose of the vaccine is 78%
● Have cancer. effective. Outbreaks can still occur even in countries such as the
● Are taking medications that impact the immune system. US, where extensive vaccine efforts are in place. For example,
● Have ever had a blood disorder. mumps outbreaks have been reported on university campuses in
● Have had another vaccine in the past month. the US (CDC, 2020n).
● Have recently had a blood transfusion or were given blood
products.
Incidence
Fortunately, mumps is no longer common in the US. Before the From January 1 to January 25, 2020, CDC reported that 16
initiation of the mumps vaccine program in 1967, approximately states in the US reported mumps infections (CDC, 2021a).
186,000 cases were reported every year. Since the initiation of Healthcare professionals should remain alert to the possibility of
the MMR vaccine, the number of reported mumps cases in the outbreaks of mumps.
US has decreased by more than 99% (CDC, 2021a).
Etiology and pathophysiology
Mumps is caused by a paramyxovirus, which is found in the of greatest communicability is most likely the 48-hour period
salivary glands of infected people. The virus is spread by direct immediately before swelling begins. The incubation period
contact or through airborne infected droplets, saliva, and, generally ranges from 16 to 18 days, but cases can occur 12 to 25
possibly, urine (Mayo Clinic, 2020d; Meadows-Oliver, 2019). days after exposure. The concentration of virus in saliva is greatest
The virus is present in the patient’s saliva for 6 days before and just before and after swelling begins (CDC, 2020n; Mayo Clinic,
up to 9 days after the onset of parotid gland swelling. The period 2020d; Meadows-Oliver, 2019).
Complications
The following complications are associated with mumps (Mayo
Clinic, 2020d; Meadows-Oliver, 2019): Figure 3: Face swollen from Mumps
● Arthritis.
● Encephalitis.
● Hearing loss.
● Inflamed ovaries.
● Inflamed testicles.
● Involvement of the auditory nerve that can cause unilateral
deafness.
● Mastitis.
● Mumps meningitis.
● Myocarditis.
● Miscarriage.
● Nephritis.
● Oophoritis.
● Pancreatitis.
CDC. (n.d.a). Mumps. https://www.immunize.org/photos/mumps-

photos.asp
The severity of presenting signs and symptoms varies drinking acidic or sour fluids. In addition, pain and swelling
significantly among patients. About 30% of people susceptible of the parotid glands and a fever of 101°F to 104°F may
to the disease have a subclinical form of the illness or extremely accompany these symptoms. Other salivary glands, in addition
mild symptoms (Mayo Clinic, 2020d; Meadows-Oliver, 2019). to the parotid glands, may become swollen (CDC, 2020n; Mayo
After an incubation period of about 18 days, prodromal Clinic, 2020d; Meadows-Oliver, 2019).
symptoms that last for about to5 days become evident, including Mumps, meningitis is a complication of mumps. Signs and
anorexia, malaise, headache, and low-grade fever (CDC, 2020n; symptoms of mumps meningitis include fever, evidence of
Mayo Clinic, 2020d; Meadows-Oliver, 2019). meningeal irritation such as nuchal rigidity, headache, irritability,
The most common symptom is parotitis, which is seen in up to and cerebrospinal fluid lymphocyte count of 500 to 2,000µL.
40% of all patients and in 95% of those who are symptomatic. Fortunately, most patients recover completely from mumps
The prodromal signs and symptoms are followed by an earache meningitis (National Health Service, 2018).
that is exacerbated by swallowing or chewing, especially when
Diagnosis
Diagnosis is usually made based on history of exposure to the by isolating the virus from a throat swab culture (Mayo Clinic,
disease and characteristic presenting signs and symptoms, 2020d; Meadows-Oliver, 2019).
especially parotid gland enlargement. Diagnosis may be confirmed
Treatment
Prognosis is good, although some patients do experience the ● Isolation (droplet precautions) for 5 days from symptom onset
previously mentioned complications. Because of the nature of or until the swelling of the parotid glands has subsided.
the disease, those complications may involve the reproductive ● Bed rest to promote adequate rest, sleep, and recovery.
organs, so the risks to adolescents and adults may be greater. ● Adequate fluid intake to prevent dehydration: Note that
Treatment consists of the following supportive measures (Mayo in cases where patients are unable to swallow because of
Clinic, 2020d; Meadows-Oliver, 2019):

swelling and pain when chewing and swallowing, intravenous not take aspirin because of the risk for developing Reye’s
fluid replacement may be necessary. syndrome.
● Warm saltwater gargles to relieve pain. ● Report all cases of mumps to the public health authorities.
● Soft, bland diet to avoid unnecessary discomfort when Healthcare professionals should teach parents and adult patients
chewing and swallowing. Spicy, irritating foods such as citrus the importance of immunization. Stress that immunization is the
juices should be avoided. best way to prevent contraction and transmission of the disease.
● Administering over-the-counter analgesics to reduce fever
and aches and pains. However, children or teenagers should
Karen is 26 years old and in the first trimester of her first A few days later Karen receives a call from her sister, who is
pregnancy. She and her husband are thrilled at the prospect of obviously distressed. “Oh, Karen, I have some bad news. One
becoming parents. Today, she is looking forward to picking up of the children at the day care center has come down with
her 3-year-old niece Allison from day care. Karen loves spending German measles. They tell me the child was never vaccinated!
time with her niece and eagerly anticipates the day when she Her parents received an exemption because of philosophical
will be spending time with her own child. reasons. She was there the day you picked up Allison. You need
to call your obstetrician right away! You’ve been exposed to
German measles!”
RUBELLA (GERMAN 3-DAY MEASLES)
Rubella, commonly referred to as German measles or 3-day is transmitted from a mother to the unborn child. Congenital
measles, is an acute, mildly contagious viral disease. It is usually rubella syndrome can lead to spontaneous abortion, stillbirth,
self-limiting, considered to be a relatively mild illness, and and multiple birth defects (CDC, 2020s; Meadows-Oliver, 2019).
seldom causes complications. The most serious form of the Therefore, appropriate vaccinations must be administered to
disease, congenital rubella syndrome, occurs when the disease prevent the transmission of the disease.
Vaccination
Children should receive two doses of MMR vaccine. The first ● Have received a vaccination within the previous 4 weeks.
dose should be given at 12 to 15 months of age and the ● Are severely or moderately ill.
second dose administered at 4 to 6 years of age. These are the In addition to the contraindications above, people should not
recommended ages, but children can receive the second dose receive the MMRV vaccine if they have a history of seizures,
at any age, as long as it is at least 28 days after the first dose. have a parent or sibling with a history of seizures, or are taking
The vaccine is safe and extremely effective. Research has shown salicylates. People should not use salicylates for 6 weeks after
that the one dose of the MMR vaccine is about 97% effective at receiving the vaccine (CDC, 2020t).
preventing rubella (CDC, 2020t).
Adults should receive the MMR vaccine if they are not in the
Adults may need to be immunized under certain circumstances. categories listed above and they (CDC, 2020t)):
Adults do not need to receive the MMR vaccine if they (CDC, ● Were born after 1956, including those who may be at
2020t; Meadows- Oliver, 2019): increased risk for exposure.
● Have had severe allergic reactions to the vaccine or its ● Are college or trade students beyond high school.
components. ● Work in healthcare facilities.
● Are pregnant or think they might be pregnant. ● Travel internationally.
● Have a weakened immune system. ● Are passengers on cruise ships.
● Have a parent or sibling with a history of immune system ● Are women of childbearing age.
problems. ● Are unvaccinated healthcare personnel born before 1957
● Have recently had a blood transfusion or have received other who lack evidence of immunity to rubella.
blood products.
● Have tuberculosis.
Rubella was eliminated from the US in 2004. Elimination is The rubella virus is transmitted via contact with nasopharyngeal
defined as the absence of continuous disease transmission for 12 secretions, blood, urine, or stools of infected people. It may
months or longer in a specific geographic region. Unfortunately, also be transmitted by contact with items such as clothing and
rubella is still found in other parts of the world and can be bedclothes that have been contaminated by the secretions of
brought into this country by persons who became infected in infected people. The virus is also passed via the placenta from
other countries. Contact with international travelers at colleges mother to unborn child (CDC, 2020r; Meadows-Oliver, 2019).
or during vacations, where close contact with others is likely, The incubation period ranges from 12 to 23 days following
will present an additional risk of transmission. Today, fewer than exposure. People are most infectious when the rash is erupting
10 cases of rubella are reported annually in the US. Since 2012, but can shed the virus from 7 days before to 7 days after the rash
evidence has shown that people infected by the virus were appears (CDC, 2020r).
infected when living or traveling outside the United States (CDC,
2020r).
Complications
Complications are rather rare in children. When they do complications are usually self-limiting and resolve within 5 to 30
occur, they often manifest as hemorrhagic problems such as days (CDC, 2020r; Meadows-Oliver, 2019).
thrombocytopenia. Young women may experience joint pain or Other complications associated with rubella that are more
arthritis that occurs just as the rash is fading. Fortunately, these serious include encephalitis, myocarditis, and hepatitis (CDC,
2020r; Meadows-Oliver, 2019).
Following an incubation period of 12 to 23 days, a ● The rash usually begins on the face.
maculopapular rash, appearing as distinct rose spots, abruptly ● The rash spreads rapidly, often covering the trunk and
erupts. Following are characteristics of this rash (CDC, 2020r; extremities within hours.
Meadows-Oliver, 2019): ● By the end of the second day, the facial rash begins to fade.

● The rash continues to fade in the order in which it appeared. Other signs and symptoms, particularly in adolescents and adults,
● The rash usually disappears by the third day but may last for include the following (CDC, 2020r; Meadows-Oliver, 2019):
4 or 5 days. ● Headache.
● Low-grade fever may accompany the rash but usually does ● Anorexia.
not last after the first day of the rash. On rare occasions ● Malaise.
temperature may reach 104°F. ● Coryza.
● Lymphadenopathy.
● Conjunctivitis.
Diagnosis
A history of exposure helps to make a diagnosis because isolate the virus. Convalescent serum that shows a fourfold rise in
the rubella rash can mimic scarlet fever, measles, infectious antibody titers corroborates the diagnosis (CDC, 2020r; Pagana
mononucleosis, roseola, and other viral rashes. Therefore, & Pagana, 2018).
cultures of throat, blood, urine, and cerebrospinal fluid can
Prognosis is generally excellent and treatment is supportive. Over- should be instituted during the period of communicability. All
the-counter medications such as Tylenol may relieve fever and rubella cases should be reported to public health officials (CDC,
joint pain. Aspirin should not be given to children or adolescents 2020r; Meadows-Oliver, 2019).
because of the danger of Reye’s syndrome. Droplet precautions
Congenital rubella syndrome
Although rubella is generally a mild, self-limiting illness, it can and microcephaly (the head is significantly smaller than normal
have devastating consequences on an unborn child. Congenital for age and sex). Experts now believe that congenital disorders
rubella syndrome (CRS) is defined as an illness that results from can also cause problems that do not appear until later in the
rubella virus infection during pregnancy. In general, the earlier affected child’s life. These problems may manifest themselves as
the infection occurs during a woman’s pregnancy, the greater the thrombocytopenic purpura, dental abnormalities, hemolytic and
damage to the fetus (CDC, 2020b). hypoplastic anemia, encephalitis, diabetes mellitus, seborrheic
Before vaccination, during the 1962-1965 worldwide epidemic, dermatitis, and giant-cell hepatitis (CDC, 2020b; Ezike, 2017;
about 12.5 million rubella cases were reported in the US, Meadows-Oliver, 2019).
resulting in 20,000 cases of CRS (Ezike, 2017). As previously Infants born with CRS should be placed on contact precautions.
noted, after vaccination programs were initiated, the incidence Research has determined that these children excrete the
of rubella and CRS drastically decreased. virus for periods ranging from several months to a year after
Intrauterine rubella infection can cause spontaneous abortions, birth. Parents of infants with CRS need a significant amount of
stillbirths, or a multitude of congenital anomalies, some of which emotional support as they attempt to deal with the physical
do not appear until later in life. Research has shown that the risk problems of the disease as well as emotions that range from
of congenital infection and anomalies is greatest during the first anger and despair to feelings of guilt. Referrals to appropriate
12 weeks of gestation and decreases after the first 12 weeks of support groups, including mental health consultations, should
gestation. Congenital anomalies are rare after the 20th week of promptly be started. Sources of financial assistance may also
gestation. Common congenital anomalies associated with CRS help. Treating a multitude of birth defects may be expensive and
are cataracts, congenital heart disease, hearing impairment, and beyond what health insurance covers. Women of childbearing
developmental delay. Hearing deficit is the most common single age should be aware of their immunization status for rubella
anomaly (CDC, 2020b; Ezike, 2017). and have their antibody levels checked as deemed appropriate.
Women who are pregnant and who believe that they may have
CRS is characterized by the presence of cataracts, deafness, been exposed to rubella should immediately contact their
or cardiac disease (CDC, 2020b; Ezike, 2017). Other common healthcare providers (CDC, 2020b; Ezike, 2017).
manifestations include low birth weight, intellectual disability,
VARICELLA (CHICKENPOX)
Varicella, more commonly known as chickenpox, is an acute, disease (Bechtel, 2018). This same virus, in its latent stage, can
common disease caused by the herpes varicella-zoster virus. It is cause herpes zoster (shingles) infection in adults, which can be a
quite contagious but is generally found to be a mild, self-limiting more serious disease.
Vaccination
The varicella virus vaccine contains a live attenuated virus. It is 3 months after the first dose. The varicella virus vaccine may be
approved for use in children 12 months of age and older and for given to older children and to adults who do not have immunity
adults. The vaccine is administered subcutaneously at 12 to 15 to the disease. In people older than 13, the second dose may be
months of age. A second dose is given at 4 to 6 years, or at least delayed only 4 weeks after the first dose is given (CDC, 2019l).
Incidence
Before the vaccine was available, varicella was widespread in the disease poses a risk for travelers to these countries (Bechtel,
US and affected about 4 million children annually. The disease 2017).
caused as many as 100 deaths in children every year and was There are some geographical differences among the rates and
responsible for an estimated $400 million in medical costs and incidences of varicella infections. In countries with temperate
lost work time. The initiation of vaccination against varicella in climates, more than 90% of people are infected by the time they
1995 significantly reduced the incidence of varicella as well as reach adolescence. In countries with tropical climates, a higher
morbidity and mortality rates. Currently, fewer than 10 deaths number of people are infected at older ages, which increases
related to varicella are reported annually, most of them occurring vulnerability in young adults (Bechtel, 2017).
in unvaccinated people. Outbreaks of the disease still occur in
schools and day care centers, usually beginning with children Varicella is still endemic in large cities throughout the world.
who are not vaccinated (Bechtel, 2017; CDC, 2018a). Outbreaks are usually found in regions with large groups of
unimmunized children. The disease affects all races and both
Varicella occurs worldwide in children who do not have immunity. sexes in equal numbers. In temperate climates incidence is
About 80 million to 90 million cases are reported annually. Most higher during late autumn, winter, and spring (Bechtel, 2017;
developing countries have low immunization rates, and the Meadows-Oliver, 2019).

Risk factors for development of severe varicella
Congenital varicella may affect infants if their mothers had acute The following factors increase the risk for severe varicella in
varicella infections during their first trimester or early in the adolescents and adults (Bechtel, 2017; Mayo Clinic, 2021b):
second trimester. Neonatal infection is rare, most likely because ● People who take high doses of steroid therapy for 2 or more
of immunity passed to infants from their mothers. However, weeks are at definite risk for severe varicella. Even short-term
neonates who are born to mothers who develop varicella 5 days therapy with high doses of steroids immediately before or
before or up to 14 days after delivery are at risk for developing during the incubation period of varicella can cause severe, or
severe varicella (Bechtel, 2017; Meadows-Oliver, 2019). even fatal, disease.
Neonates are especially susceptible to severe varicella in the first ● Children with cancer are at increased risk for severe varicella.
month of life. This is especially true if the mother is not immune The risk is greatest for children with leukemia. Nearly 30%
to the disease. Early delivery is also a risk factor for severe forms of these children whose immune systems are compromised
of the disease. Birth before 28 weeks of gestation increases and who have leukemia have severe varicella; 7% of these
susceptibility because transmission of immunoglobulin antibodies affected children may die.
from the mother to the baby occurs after this time (Bechtel, 2017; ● People with compromised immune systems caused by such
Mayo Clinic, 2021b)). conditions as cancer, taking anticancer drugs, or HIV/AIDS
infection are at risk for severe varicella.
● Pregnant women are at high risk of severe varicella.
Complications
Although rare in healthy children, several complications are infection poses a risk for life- threatening respiratory compromise
associated with varicella (Bechtel, 2017; Mayo Clinic, 2021be; and has a mortality rate of 14%. Before the development of
Meadows-Oliver, 2019): antiretrovirals, the mortality rate was 45% (Marino, 2017).
● Arthritis. Infection during pregnancy can lead to congenital varicella
● Pneumonia. syndrome (CVS) that may result in the following (Marino, 2017):
● Encephalitis. ● Spontaneous abortion.
● Hemorrhagic varicella. ● Cataracts.
● Hepatitis. ● Limb atrophy.
● Myocarditis. ● Cerebral cortical atrophy.
● Nephritis. ● Neurological disability.
● Reye’s syndrome.
● Secondary bacterial infections of varicella lesions. If the mother is infected in the perinatal period, particularly 5
● Thrombocytopenia. days before delivery or 2 days after, there is a risk of severe
neonatal varicella, which has a mortality rate of 30%. Infection
The varicella-zoster virus also places both mother and fetus during this time inhibits maternal antibody development. This
at risk for complications if infection occurs during pregnancy. means that the fetus does not receive passive immunity from the
Primary varicella infection during pregnancy is considered to be mother (Marino, 2017).
a medical emergency. Pneumonitis as a result varicella-zoster
Etiology and pathophysiology
Varicella is caused by the herpes varicella-zoster virus and which takes about 5 to 7 days (CDC, 2018a; Meadows-Oliver,
is highly communicable. The virus is transmitted by direct 2019; Mayo Clinic, 2021b).
contact, especially with respiratory secretions, by contact with The varicella virus enters the body through the respiratory
skin lesions, droplet spread, and airborne transmission. The system and colonizes in the upper respiratory tract. The virus
incubation period ranges from 14 to 16 days but can be as replicates in regional lymph nodes. After about a week, it moves
short as 10 days or as long as 21 days. The disease is most likely to the viscera and skin, causing lesion eruptions characteristic
communicable from the onset of fever, which is about 1 to 2 of varicella. CNS or liver infection may also occur at this time, as
days before the first lesion appears, until the last vesicle dries, may the complications of encephalitis, hepatitis, or pneumonia
(Bechtel, 2017; CDC, 2018a; Meadows-Oliver, 2019).
The incubation period for varicella is 10 to 21 days. The disease vesicles on an erythematous (red) base, sometimes referred to
is communicable beginning up to 5 days before the body rash as “dewdrop on a rose petal.” These lesions become cloudy
appears and continues until all of the lesions on the skin are and break easily, causing scabs (Bechtel, 2017; CDC, 2018a;
crusted over (Meadows-Oliver, 2019). Meadows-Oliver, 2019).
Varicella causes characteristic signs and symptoms, the most The rash first appears on the head and mucous membranes, then
predominant of which is a pruritic (extremely itchy) rash. During spreads over the trunk of the body to the limbs, axillae, upper
the prodromal phase of the disease, the patient develops a low- respiratory tract, conjunctivae, and, occasionally, the genitalia.
grade fever, malaise, and anorexia. Within 24 hours the patient New vesicles continue to form for about 3 or 4 days. This means
develops the characteristic varicella rash (Bechtel, 2017; CDC, that the rash consists of papules, vesicles, and scabs all at the
2018a; Mayo Clinic, 2021b). same time. The rash causes severe pruritus. Patients, especially
The rash associated with varicella usually starts as crops of small young children, may be unable to control the urge to scratch the
red flat spots (macules) on the trunk or scalp. The macules rash, which can lead to infection, scarring, impetigo, and even
become papules (elevated lesions) and then progress to clear cellulitis (Bechtel, 2017; CDC, 2018a; Meadows-Oliver, 2019).
Diagnosis
Diagnosis seldom requires laboratory testing because the clinical Tzanck smear, which shows multinucleated giant cells, or Giemsa
manifestations are generally quite characteristic and are usually stain, which differentiates varicella-zoster from vaccine and
accompanied by a history of exposure. The virus can be isolated variola viruses (CDC, 2020b;
from vesicular fluid within the first 3 or 4 days of the rash’s Ezike, 2017).
appearance if necessary. If needed, diagnostic tests include
The prognosis for healthy children is excellent. In children ages rate is two deaths per 100,000 cases. Children with deficient
1 to 14 years who are otherwise healthy, the estimated mortality

immune systems are at higher risk for severe disease and death Parents and other caregivers should take their children (or
(Bechtel, 2017; CDC, 2018a; Meadows-Oliver, 2019). patients of other ages) to an emergency department if the
Treatment is primarily symptomatic and consists of the following following signs and symptoms occur (Bechtel, 2017 Meadows-
interventions (Bechtel, 2017; CDC, 2018a; Meadows-Oliver, Oliver, 2019):
2019): ● Refusal to drink fluids.
● Droplet and contact isolation until all vesicles and the ● Signs of dehydration such as oliguria, increasing drowsiness,
majority of the scabs dry and no new lesions appear: This is and excessive thirst.
usually about 1 week after onset of the rash. ● Unusual redness, pain, or swelling over the rash.
● Lukewarm oatmeal or baking soda baths and calamine lotion ● Confusion.
to reduce pruritus. Age-appropriate oral antihistamines to ● Unusual weakness.
reduce pruritus. ● Inability or difficulty walking.
● Over-the-counter medications such as Tylenol may be given ● Complaints of severe headache or stiff neck and back pain.
for fever, but aspirin and other salicylates should be avoided ● Frequent vomiting.
in children and adolescents because of the risk of Reye’s ● Difficulty breathing.
syndrome. ● Chest pain.
● Shorten fingernails to prevent scratching. Have children wear ● Severe cough.
mittens to help avoid scratching, especially while sleeping. ● Fever that lasts more than 4 days or a fever that returns after
the original fever subsides.
Patients (including newborns) who are at risk for severe
disease may be given varicella-zoster immunoglobulin within
10 days (ideally within 4 days) of exposure (Bechtel, 2017).
This may offer some passive immunity. Antiviral agents such Parents ask the nurse practitioner when their child, who has
as acyclovir (Zovirax) may be administered to patients over 12 been diagnosed with varicella, may return to school. The nurse
years of age within the first 24 hours to help slow formation practitioner tells the parents:
of vesicles, facilitate skin healing, and control the spread of
infection systemically (Bechtel, 2017; CDC, 2018a; Meadows- a. When all of the lesions are crusted over.
Oliver, 2019). Pregnant patients with varicella need appropriate b. When fever has subsided for 24 hours.
monitoring and follow-up care from their healthcare providers. c. Five days after the appearance of the rash.
Young adult females should consider an immunization review to d. Two days after the lesions are completely gone.
avoid the risks associated with pregnancy and newborns.
Janice is 54 years old and a professor of nursing at a large is affecting her in an unusual way. Within 2 days she begins to
metropolitan university. She suffers from severe arthritis and experience severe deep pain and pruritus over the cervical area
has just finished a course of steroid therapy in the hopes of of her back. Within another day or two, Janice develops a rash
decreasing the inflammatory effects of the disease. For the consisting of small red nodular lesions over the painful areas.
past few days, Janice has not been feeling very well. She has a These lesions are quickly turning to vesicles. Janice’s husband
slight fever, is unusually fatigued, and complains of having no drives her to their family doctor where, as Janice fears, she
energy. Janice wonders if she has a virus or if the steroid therapy receives a diagnosis of shingles.
SHINGLES (HERPES ZOSTER)
CDC. (n.d.b). https://www.cdc.gov/shingles/about/photos.html
Figure 3: Shingles rash on the neck
Shingles, or herpes zoster, is an inflammatory condition that
occurs when the varicella-zoster virus reactivates and causes
vesicular eruption along the pathway of the nerves from one or
more dorsal root ganglia (dermatome). Shingles generally affects
adults who are over the age of 40. Severe neuralgic pain occurs
in peripheral areas that are fed by the nerves coming from the
inflamed ganglia (Lippincott Williams & Wilkins, 2017).
Although most people recover completely, there may be
scarring, residual neuropathic pain, and visual impairment if
the cornea is affected. Anyone over the age of 50 who has had
varicella should receive the shingles vaccine (Shingrix) to prevent
the disease (Lippincott Williams & Wilkins, 2017).
Vaccination
Because most older adults have had varicella as children, millions months. The Shingrix injection is administered in the upper arm
of people are vulnerable to developing shingles. The shingles (CDC, 2020u).
vaccine has been approved for people age 50 and older. People Two doses of Shingrix are more than 90% effective at preventing
who have had shingles in the past may get Shingrix to help shingles and PHN. Protection stays above 85% for at least the
prevent future occurrences of shingles (CDC, 2020u; Mayo first 4 years following vaccination (CDC, 2018a; CDC, 2018e;
Clinic, 2020h). CDC, 2020u).
The latest recommendations from CDC regarding shingles Research has shown the effectiveness of Shingrix in the following
vaccination are that healthy adults 50 years of age and older populations (CDC, 2020f):
should receive two doses of the shingles vaccine (whether ● In adults 50 to 69 years of age who got two doses, Shingrix
they have received Zostavax, which is no longer in use in the was 97% effective in preventing shingles.
US) called Shingrix to acquire protection from shingles and ● In adults 70 years and older who received two vaccine doses,
post-therapeutic neuralgia (PHN), which is the most common Shingrix was 91% effective.
complication of shingles. There is no maximum age for receiving ● In adults 50 to 69 years old who received two doses, Shingrix
the shingles vaccine. Doses should be separated by2 to 6 was 91% effective in preventing PHN.
● Among adults 70 years and older, Shingrix was 89% effective.

Side effects of the vaccine include pain, redness, swelling, or The following groups of people should not receive the shingles
itching at the injection site; headaches; muscle pain; fever; vaccine (CDC, 2020u; Comerford & Durkin, 2021):
stomach pain and nausea; and fatigue. About one in six people ● People who have had a life-threatening reaction to gelatin,
have side effects that affect their ability to perform normal daily neomycin, or any other component of the shingles vaccine.
activities for 2 to 3 days. Severe allergic reactions are very rare. ● People who have tested negative for immunity to varicella-
Note that Shingrix will not cure herpes zoster once it occurs (CDC, zoster virus. In this case they should receive the varicella
2020u; Comerford & Durkin, 2021). vaccine.
It is recommended that patients receive Zostavax even if in the ● People who currently have shingles.
past they had shingles, received Zostavax, or are not sure if they ● People who have a moderate or severe acute illness. They
had varicella in the past (CDC, 2018b). should wait until they recover before getting the vaccine.
● Women who are pregnant, who might be pregnant, or who
are breastfeeding.
Shingles is a reactivation of the varicella virus that primarily affects two CDC studies found that herpes zoster rates started increasing
adults, especially those older than 60. The virus has been dormant before varicella vaccine was introduced in the United States
in the cerebral ganglia of the cranial nerves or the ganglia of and did not accelerate after the routine varicella vaccination
posterior nerve roots after having had varicella (CDC, 2020u). program started (CDC, 2020u). Other countries that do not have
The reason for this reactivation is unknown. After the primary routine varicella vaccination programs have also observed similar
infection (varicella), the varicella-zoster virus may live in a dormant increases in herpes zoster rates (CDC, 2020u).
state in the dorsal nerve root ganglia. Years later the virus may Unfortunately, the rate of shingles is increasing among adults in
emerge from its dormant state, either spontaneously or as the the US. This increase has been gradual and progressive, and the
result of immunosuppression. Some experts believe that the virus reason has yet to be identified. Some experts are concerned that
multiplies as it reactivates, and antibodies that remain from the routine varicella vaccination may actually increase the incidence of
initial varicella infection deactivate it. But if an adequate number shingles in adults because it decreases their exposure to varicella
of effective antibodies does not remain, the virus continues its (CDC, 2020u).
multiplication process in the ganglia, destroying the neurons that Following are disease rates for shingles (CDC, 2020u):
harbor it. The virus then moves down the sensory nerves to the ● About 1 million cases of herpes zoster occur annually in the
patient’s skin (CDC, 2020u; Mayo Clinic, 2020h). US.
Herpes zoster rates are increasing among adults in the United ● The incidence of herpes zoster is about four cases per 1,000
States, especially among younger adults. The increase has been US population annually.
gradual over a long period. We do not know the reason for this ● About 1% to 4% of people with herpes zoster are
increase. The rates among older adults are plateauing (CDC, hospitalized for complications.
2020u). ● Older adults and people with compromised immune systems
Some experts suggest that exposure to varicella boosts a person’s are more likely to be hospitalized.
immunity to varicella zoster virus (VZV) and reduces the risk for ● About 1 in 10 adults with herpes zoster develop PHN.
VZV reactivation. Thus, they are concerned that routine childhood ● About 96 deaths occur annually in which herpes zoster was
varicella vaccination, recommended in the United States since the actual underlying cause. Almost all deaths occur in older
1996, could lead to an increase in herpes zoster in adults because adults or those with compromised or suppressed immune
of reduced opportunities for being exposed to varicella. However, systems.
Risk factors
Some factors can increase the risk of contracting shingles. Other possible risk factors that are under investigation but not
People with compromised immune systems are at particular yet conclusively supported by research findings include the fact
risk, including those who have cancer, especially leukemia and that women seem to develop shingles more often than men.
lymphoma; have HIV/AIDS; have undergone bone marrow or Most studies support this finding. Some research findings from
solid organ (heart, liver, lung) transplantation; or are taking studies in the US as well as other countries indicate that shingles
drugs that suppress the immune system such as steroids, is less common in African Americans by about 50% than in
chemotherapy, or immunosuppressive medications related to Whites (CDC, 2020u; Lippincott Williams & Wilkins, 2017; Mayo
transplantation (CDC, 2020u; Mayo Clinic, 2020h). Clinic, 2020h).
Complications
Complications associated with shingles include chronic pain include corneal ulcers, keratitis (corneal inflammation), uveitis
syndrome. About 20% of patients develop chronic pain (inflammation of the middle layer of the eye), and even
syndrome. This syndrome is characterized by pain that can blindness. There also can be damage to the facial or auditory
be described as a constant aching and burning sensation, nerves, which can lead to hearing loss, vertigo, and facial
intermittent, sharp and cutting, or hyperesthesia (excessive weakness. Inflammatory processes that can cause pneumonitis,
physical sensitivity) of affected areas of the skin after it has esophagitis, myocarditis, and pancreatitis may also occur (CDC,
healed. Visual complications may also occur. Examples 2020u; Lippincott Williams & Wilkins, 2017; Mayo Clinic, 2020h).
Initially, shingles causes fever, headache, and malaise. Within Small red nodular-like skin lesions erupt over the painful areas of
2 to 4 days, the patient begins to experience severe, deep the skin, often within 3 to 4 days of initial symptoms, but these
pain; pruritus; and paresthesia or hyperesthesia on the trunk lesions can take as long as 14 days to appear. These lesions
and sometimes on the arms and legs. Some patients report usually spread unilaterally around the thorax or vertically over
that even air movement on the lesions can be quite painful and the arms and legs. They appear as patches of vesicles that erupt
that wearing clothing over the area causes intense pain. The in groups and appear on erythematous, edematous skin. The
pain can be constant or intermittent and generally lasts from 1 lesions quickly become vesicles that fill with pus or clear fluid.
to 4 weeks. Inflammation is usually unilateral and involves the These vesicles later rupture and form crusts about 10 days after
cranial, cervical, thoracic, lumbar, or sacral dermatome (area of they appear. Fortunately, scarring seldom occurs unless the
skin that is innervated by a single spinal nerve) in a “bandlike” vesicles are located deep within the skin and involve the dermis.
configuration (CDC, 2020u; Lippincott Williams & Wilkins, 2017; If vesicles rupture, they can become infected and can lead to
Mayo Clinic, 2020h). lymphadenopathy of regional lymph nodes. Some infected
ruptured vesicles can even become gangrenous.

Vesicles that appear on the tip of the nose indicate involvement A vulnerable person can acquire varicella if they come into
of the eye. If the ophthalmic branch of the facial nerve is contact with the infected vesicular fluid of a shingles patient. But a
affected, the eye may become painful, which can ultimately person who has had varicella, or who has been vaccinated against
become a medical emergency. varicella, is immune and not at risk for infection after exposure to
In otherwise healthy patients, lesions resolve within 2 to 3 weeks patients with shingles (CDC, 2020u; Mayo Clinic, 2020h).
(CDC, 2020u; Lippincott Williams & Wilkins, 2017).
Diagnosis
Diagnosis is usually made based on the patient’s clinical The varicella-zoster virus can be cultured from vesicular fluid
presentation of characteristic skin lesions. Before the appearance and infected tissue to confirm diagnosis. A Tzanck test of
of the lesions, the intense pain may be mistaken for appendicitis, vesicular fluid and infected tissue shows eosinophilic intranuclear
pleurisy, or other conditions that trigger severe pain (Lippincott inclusions and varicella virus (Lippincott Williams & Wilkins, 2017;
Williams & Wilkins, 2017; Mayo Clinic, 2020h). Pagana & Pagana, 2018).
The foundation of shingles treatment is antiviral therapy, which is help them cope with severe discomfort. Reassure them that the
administered to stop the characteristic rash from progressing and pain will eventually subside, and teach them relaxation strategies
to prevent complications. Such drugs include acyclovir (Zovirax), such as meditation or deep breathing exercises (Lippincott
famciclovir (Famvir), and valacyclovir (Valtrex). They interfere with Williams & Wilkins, 2017; Mayo Clinic, 2020h).
viral replication and can be prescribed for all patients, but are Also, patients should be educated about proper handwashing
especially helpful when treating patients who have compromised techniques and encouraged to wash their hands frequently to
immune systems or who are debilitated. Antiviral treatment is avoid spreading the infection. It is also important to explain to
most effective when initiated within 72 hours of disease onset. patients how important it is to avoid scratching because this can
If ruptured vesicles have been infected by bacteria, appropriate cause vesicular rupture, which can cause bacterial infection and
antibiotics are prescribed. If the disease has affected the cornea, scarring (Lippincott Williams & Wilkins, 2017; Mayo Clinic, 2020h).
ophthalmic antiviral ointments are prescribed (Comerford & Durkin,
2021; Lippincott Williams & Wilkins, 2017; Mayo Clinic, 2020h). Self-Assessment Quiz Question #6
Additional treatment measures for pain management include the
following (Mayo Clinic, 2020h): A nurse is counseling a 55-year-old male patient about
● Capsaicin topical patch (Qutenza). vaccination for shingles. The patient had shingles 2 years ago.
● Anticonvulsants such as Neurontin. The nurse should explain that:
● Tricyclic antidepressants. a. The patient should not receive the shingles vaccine because
● Numbing agents such as lidocaine. he has already had shingles.
● Narcotic analgesics such as codeine. b. Two doses of Shingrix for persons in his age group are 97%
● Corticosteroid injections and local anesthetics. effective in preventing shingles.
● Antiviral drugs such as acyclovir (Zovirax), famciclovir, and c. The patient should receive two doses separated by 2 to 6
valacyclovir (Valtrex). weeks.
Patients need emotional support as they deal with severe pain. d. Research shows that Shingrix is not effective in adults 70
Encourage patients to take analgesics on a regular schedule to years and older.
HEPATITIS A AND B
Hepatitis is a general term that refers to liver inflammation. may remain infectious and are capable of transmitting the
Causes are both infectious (viral, bacterial) and noninfectious disease for many years (Lippincott Williams & Wilkins, 2017;
(alcohol, drugs, autoimmune diseases). Viral hepatitis accounts Samji, 2017).
for more than 50% of acute hepatitis cases in the United States Other hepatotropic viruses that can cause hepatitis are hepatitis
(Samji, 2017). D virus (HDV), hepatitis E virus (HEV), and hepatitis G virus
The most common viral forms of hepatitis in the United States (HGV). Additionally, there are infrequent causes of the disease
are hepatitis A, B, and C (HAV, HBV, HCV). All three of these such as Epstein-Barré virus (EBV), adenovirus, cytomegalovirus
viruses can cause acute illness. HBV and HCV can also lead to (CMV), and, rarely, herpes simplex virus (HSV; Samji, 2017). To
chronic infection, which may ultimately progress to cirrhosis and date vaccinations are available only for hepatitis type A and type
hepatocellular carcinoma. Persons who have chronic hepatitis B (Lippincott Williams & Wilkins, 2017).
HEPATITIS A
Hepatitis A, a highly contagious disease, is caused by infection It is transmitted primarily by the fecal-oral route by either
with the hepatitis A virus (HAV). Hepatitis A, also known as person-to-person contact or by consuming food or water that
infectious or short- incubation hepatitis, has an acute onset is contaminated. Infections that occur in the United States
and most often affects children and young adults. Hepatitis A are primarily linked to travel to another country where HAV
is usually a mild disease with a generally good prognosis. It is transmission is common, close personal contact with infected
self-limiting and does not cause chronic infection or chronic liver persons, sex among men who have sex with men, and behaviors
disease (CDC, 2020aa; Lippincott Williams & Wilkins, 2017). associated with drug use (CDC, 2020aa; CDC, 2020bb;
Lippincott Williams & Wilkins, 2017).
Incidence
HAV is one of the most common causes of foodborne infection the age of 10. However, epidemics are uncommon in these
and occurs sporadically and in epidemics throughout the world. countries because older children and adults are generally
In developed countries with proper sanitary conditions, infection immune. An estimated 7,134 people died from hepatitis A in
rates are low. In developing countries with regions of inadequate 2016 (WHO, 2020c).
sanitation, 90% of children have been infected with HAV before
Risk factors
People at risk include those who have not been vaccinated or are men who have sex with men and people who have chronic
previously infected and those who live in areas where the virus hepatic disease. Other risk factors include the following (CDC,
is widespread, such as developing countries. Also at high risk 2020aa; CDC, 2020bb; Nettleman, 2020; WHO, 2020c):

● Living in conditions that have poor sanitation and lack of safe ● Traveling to areas where the disease is endemic without
water. being immunized.
● Using injectable drugs. ● Having chronic liver disease.
● Living in close contact with an infected person. ● Needing to frequently receive blood products.
Disease course
The incubation period for HAV ranges from approximately 15 recovery for a return to work, school, or normal daily activities.
to 45 days. Prognosis is generally good with complete recovery This can have a significant interpersonal and economic impact
likely. However, it can take weeks or even months for complete on patients and families (Lippincott Williams & Wilkins, 2017).
Signs and symptoms
Some people infected with HAV have no symptoms. Adults are ● Vomiting.
more likely to have severe symptoms and a prolonged disease ● Diarrhea.
course. Signs and symptoms range from mild to severe and can ● Pain in the right upper quadrant.
include the following (Nettleman, 2020; WHO, 2020c): ● Dark colored urine.
● Low-grade fever. ● Jaundice.
● Malaise. Patients shed large amounts of the virus in their feces beginning
● Anorexia. about 2 weeks before symptom onset and continuing for 1 to 3
● Headache. months (Nettleman, 2020).
● Clay-colored stools.
Diagnosis
Diagnosis is confirmed when antibodies to HAV are detected in infection. Once someone has recovered from HAV, they are
the bloodstream. HAV infection does not cause chronic hepatic immune to the disease for life (Nettleman, 2020; WHO, 2020c).
Vaccination for HAV infection
There are two approved HAV vaccines currently available in the The risks associated with receiving the hepatitis A vaccine
US: Havrix and Vaqta. Both are injected into the deltoid muscle. include the following (CDC, 2020aa):
There is also a combination vaccine to protect against HAV and ● Soreness at the injection site.
HBV infection called Twinrix, which requires three doses over a ● Headache.
period of 6 months (CDC, 2020aa; Nettleman, 2020). ● Loss of appetite.
Vaccination is the most effective way to prevent HAV ● Fatigue.
transmission. The Advisory Committee on Immunization ● Fever.
Practices (ACIP) recommends that the following persons be Sexually active adults are not considered at risk for HAV unless
vaccinated against HAV (CDC, 2020aa): they live with or are having sex with an infected person, inject
● All children at age 1 year: This is to avoid interference by drugs, or have chronic liver disease. It is important that nurses
passive maternal anti-HAV that may be present during the know (and relay to their patients) that interventions generally
infant’s first year of life. used to prevent the transmission of sexually transmitted
● Persons who are at increased risk for infection. diseases (STDs), such as use of condoms, do not prevent
● Persons who are at increased risk for complications from HAV. HAV transmission. Vaccination is the most effective means of
● Any person who wants to obtain immunity or protection from preventing HAV infection (CDC, 2020bb). Some food service
infection with HAV. personnel may be required to be vaccinated to prevent
transmission of the disease. Frequent handwashing should be
encouraged.
HEPATITIS B
Type B hepatitis (HBV) is caused by the hepatitis B virus, which HBV is a potentially life-threatening infection that not only
can cause both acute and chronic liver disease. It affects all age causes chronic hepatic infection, but also puts patients at high
groups but poses a significant hazard for healthcare workers risk of death from liver cancer and cirrhosis of the liver (WHO,
because it is transmitted via contact with blood or other body 2020d).
fluids that are infected with the virus (WHO, 2020d).
Incidence and transmission
HBV is a global health problem with the highest prevalence in ● Sexual contact through blood, semen, saliva, or vaginal
WHO Western Pacific region and WHO African region, where secretions: HBV is deemed to be a sexually transmitted
6.2% and 6.1%, respectively, of the adult population are infected disease.
(WHO, 2020d). An estimated 257 million people are living with ● Orally through breastfeeding or saliva.
HBV infection throughout the world. In 2015, there were 887,000 ● Parenteral route through injection equipment, needles, or
HBV-related deaths (WHO, 2020d). The age-adjusted hepatitis syringes that have been contaminated.
B-related mortality rate decreased from 0.46 per 100,000 US ● Parenteral route among people who are injectable drug
population in 2017 to 0.43 in 2018, below the 2018 target rate users.
of 0.45 (CDC, 2021d). ● Contact with contaminated body fluids in the healthcare
HBV is transmitted primarily through contact with infected blood, setting, often because of wearing defective gloves.
but there are also other means of transmission, including the ● Maternal-neonatal transmission.
following factors (Lippincott Williams & Wilkins, 2017; WHO, HBV is not spread by contaminated food or water. It is generally
2020d): not spread casually in the workplace (WHO, 2020d).
Complications
A number of serious complications accompany HBV, including ● Lymphoma.
the following (Lippincott Williams & Wilkins, 2017; WHO, 2020d): HBV infection can progress to chronic infections. For example
● Chronic active hepatitis. (WHO, 2020d):
● Liver cancer. ● 80% to 90% of infants infected during the first year of life
● Cirrhosis of the liver. develop chronic infections.
● Pancreatitis.

● Some 30% to 50% of children infected before age 6 develop ● Fewer than 5% of otherwise healthy adults who are infected
chronic infections. develop chronic infection. About 20% to 30% of adults who
are chronically infected will develop cirrhosis or liver cancer.
Risk factor
People at risk for HBV infection include the following (Lippincott ● Patients with chronic hepatic disease.
Williams & Wilkins, 2017; WHO, 2020d): ● People who have HIV/AIDS.
● People who live in geographic regions where the disease is ● People who have multiple sexual partners.
prevalent. ● Men who have sex with men.
● People who travel to geographic regions where the disease ● Healthcare personnel who have close regular contact with
is prevalent. these patients or have had a needle stick from a known case.
● Those who use injectable drugs. The global prevalence of HBV infection in HIV-infected persons
● People who receive blood products frequently. is 7.4%. Since 2015, WHO has recommended treatment for
● Healthcare workers who are exposed or have a risk of everyone with HIV, regardless of the stage of the disease.
exposure to infected patients’ body fluids. Tenofovir, which is included in the treatment combinations
● Household and intimate contacts of patients who have HBV recommended for HIV treatment, is also active against HBV
infection. (WHO, 2020d).
● Dialysis patients.
Disease course
HBV has an incubation period of 30 to 180 days, with an average People infected in adulthood are less likely than children to
of 75 days. The HBV virus can survive outside the body for at progress to chronic infection. Fewer than 5% of otherwise
least 7 days, during which time it can cause infection if it enters healthy adults progress to chronic infections. But 15% to 25%
the body of an unimmunized person (WHO, 2020d). of adults who become chronically infected as children die from
cirrhosis or hepatic cancer related to HBV (WHO, 2020d).
Signs and symptoms
HBV has an insidious onset and some people do not have ● Jaundice.
symptoms during the acute infection phase. Those who do ● Dark urine.
may experience 1 week to 2 months of prodromal symptoms, ● Arthritis.
including the following (Lippincott Williams & Wilkins, 2017; ● Skin rashes.
WHO, 2020d): ● Urticaria.
● Anorexia. ● Myalgia.
● Fatigue. ● Pruritus.
● Nausea. ● Photophobia.
● Vomiting. ● Changes in the senses of taste and smell.
● Headache. Although the disease is usually severe and there is a risk for
● Transient fever. severe complications, more than 90% of healthy adults infected
● Abdominal pain. with HBV recover completely within a year (WHO, 2020d).
As the disease progresses, patients may experience the
following (Lippincott Williams & Wilkins, 2017; WHO, 2020d):
Diagnosis
Diagnosis is confirmed when antibodies to HBV are detected. reveal transient neutropenia and lymphopenia followed by
Other laboratory tests of significance that support a diagnosis lymphocytosis (Lippincott Williams & Wilkins, 2017; Pagana &
of hepatitis include elevated serum alkaline phosphatase levels Pagana, 2018).
and elevated serum bilirubin levels. White blood cell counts
Vaccination
HBV vaccine has reduced the number of new cases in the US by just under 1% in 2019, down from around 5% in the pre-vaccine
more than 75%. WHO recommends that all infants receive the era ranging from the 1980s to the early 2000s (WHO, 2020d).
hepatitis B vaccine as soon as possible after birth, preferably This marks the achievement of one of the critical targets to
within 24 hours (WHO, 2020d). The birth dose should be eliminate viral hepatitis in the sustainable development goals: to
followed by two or three doses to complete the primary series. reach under 1% prevalence of HBV infections in children under 5
According to latest WHO estimates, the proportion of children years of age by 2020 (WHO, 2020d).
under 5 years of age chronically infected with HBV dropped to
Management of hepatitis A and HB and nursing considerations
Chronic hepatitis B can be treated with antiretroviral medications ● Encourage at least 4 quarts of fluids per day. Offer ice chips
such as lamivudine (Epivir), which decreases the viral load of and effervescent soft drinks. They help to hydrate the patient
hepatitis B. But the majority of treatment interventions, including without triggering vomiting.
the following, are supportive and similar for all forms of hepatitis ● Administer antiemetics about 30 minutes before meals to
(Lippincott Williams & Wilkins, 2017; WHO, 2020d): relieve nausea and prevent vomiting. Phenothiazines have a
● Facilitate rest and sleep according to the patient’s age and cholestatic effect and should not be administered.
level of fatigue. ● If signs or symptoms of precoma – such as lethargy,
● Provide a quiet and calm environment with diversionary confusion, or mental changes – develop, reduce protein
activities that combat anxiety and boredom but do not intake. If the patient is not hospitalized, seek immediate
overexcite or stress the patient. emergency medical help if such symptoms develop.
● Hospitalize patients who have excessive vomiting or life- ● Gradually increase physical activity after jaundice resolves.
threatening complications. ● Implement enteric precautions and teach members of the
● Provide small high-calorie, high-protein meals to fight same household and close contacts how to implement
anorexia. enteric and standard precautions.

● Provide emotional support and encouragement. Explain that
it may take months for jaundice to clear completely and for
physical energy to return. Patients with HBV need to know that:
a. It is considered to be a sexually transmitted disease.
b. HBV is typically a mild disease that does not cause chronic
infection or chronic liver disease.
c. Transmission routes include spread by food or water.
d. HBV has a short incubation period of about 2 weeks after
being infected.
MENINGOCOCCAL MENINGITIS (BACTERIAL MENINGITIS)
After eight cases of group B meningococcal disease at Princeton vaccine uses four antigens from serogroup B strains that provide
University and four cases at University of California, Santa protection from about 78% of the more than 1,000 identified
Barbara, health authorities have taken an unusual pathway to strains of type B (Youngdahl, 2014).
using a vaccine that is not licensed in the United States. More The virulence of certain strains of meningococcal disease has led
than 5,000 Princeton students and staff members with certain to changes in the vaccination of people at risk for the disease
medical conditions have received one dose of a meningitis B under certain circumstances, as shown by the preceding excerpt,
vaccine (Bexsero) approved for use in the outbreak by FDA which describes a situation that helped to trigger awareness of
under an Expanded Access to Investigational New Drug vaccination needs. Meningococcal meningitis can have severe
protocol. Students will receive the second of the two needed consequences, including death. Outbreaks occur in populations
doses in February. Regulatory agencies in the European Union, that live in close quarters such as college dormitories, nursing
Canada, and Australia approved this meningitis B vaccine in homes, and military barracks (WHO, 2018b).
2013, but the U.S. FDA has not reviewed it for use here. The
Meningitis is defined as an inflammation of the meninges that adolescence. Among adolescents and young adults, those 16
surround the brain and spinal cord. Inflammation can affect all through 23 years old have the highest rates of meningococcal
three meningeal membranes: the dura mater, arachnoid, and pia disease (CDC, 202l).
mater membranes. The most common form of meningitis is viral Untreated bacterial meningitis is associated with up to a 50%
and often clears on its own within 10 days (Lippincott Williams & mortality rate and the possibility of severe brain damage.
Wilkins, 2017; WHO, 2018b). Especially virulent forms of the disease may be fatal within a
Meningococcal meningitis, commonly referred to as bacterial matter of hours (WHO, 2018c).
meningitis, is a bacterial form of meningitis caused by the The highest rates of the disease are found in sub-Saharan Africa.
gram-negative bacteria Neisseria meningitidis and is a much About 30,000 cases are reported in this region every year (WHO,
more serious form of the disease compared to viral meningitis 2020b). Migratory populations from wars and famine in this area
(Lippincott Williams & Wilkins, 2017, WHO, 2018b). have contributed to the spread of the disease.
Rates of meningococcal disease have been declining in the Although several different types of bacteria can cause meningitis,
United States since the late 1990s. In 2018, about 330 cases Neisseria meningitidis is the type with the potential to trigger
of meningococcal disease were reported. Anyone can get large epidemics of meningitis (WHO, 2018b).
meningococcal disease, but rates of disease are highest in
children younger than 1 year old, followed by a second peak in
Transmission and pathophysiology
The disease is transmitted from person to person via respiratory ● Group B Streptococcus and E. coli: Mothers can pass these
droplets or throat secretions. Close, prolonged contact such as bacteria to their babies during birth.
kissing or living with large groups of people in close quarters ● Hib and S. pneumoniae: People spread these bacteria by
– such as in military barracks, migratory camps, or college coughing or sneezing when in close contact with others who
dormitories – facilitate the spread of the disease (CDC 2020l; breathe in the bacteria.
WHO, 2018b). ● N. meningitidis: People spread these bacteria by sharing
The Neisseria bacteria infect only humans. The bacteria can respiratory or throat secretions (saliva or spit). This typically
overwhelm the body’s immune system and spread rapidly occurs during close (coughing or kissing) or lengthy (living
through the bloodstream to the brain. It is believed that about together) contact.
10% to 20% of the population carries Neisseria in their throats ● E. coli: People can get these bacteria by eating food
at any given time. Why some people develop the disease and prepared by people who did not wash their hands well after
others do not is still not understood (WHO, 2018b). using the toilet. People usually get sick from E. coli and L.
monocytogenes by eating contaminated food.
Here are some common examples of how bacterial meningitis is
spread (CDC, 2020l):
Complications
A number of complications are associated with bacterial ● Headache.
meningitis. Children who acquire the disease are especially ● Paralysis.
vulnerable to becoming deaf and having learning difficulties, ● Vasculitis.
spasticity, paresis, or cranial nerve disorders. Seizures occur ● Respiratory failure.
in 20% to 30% of all patients. Edema of the brain may cause ● Septic arthritis.
herniation or compression of the brain stem (WHO, 2018b). ● Pericarditis.
Other complications that may occur include the following ● Endophthalmitis.
(Lippincott Williams & Wilkins, 2017; WHO, 2018b): ● Neurologic deterioration.
● Visual impairment. ● Death.
● Optic neuritis.
● Cranial nerve palsies.
● Personality changes.

The average incubation period for meningococcal meningitis is With Brudzinski’s sign, the patient is placed in the dorsal
4 days, but it can range from 2 to 10 days (WHO, 2018b). Classic recumbent position and the head is flexed upward. Meningeal
symptoms include fever, headache, and nuchal rigidity (stiff irritation is indicated if neck flexion causes flexion of hips,
neck). Patients may also experience vomiting, diarrhea, cough, knees, and ankles. If the patient also flexes their hips and knees,
and myalgia (muscle pain) (Lippincott Williams & Wilkins, 2017; there may be meningeal irritation and inflammation, which are
WHO, 2018b). indicators of meningitis (Lippincott Williams & Wilkins, 2017).
Confusion and altered mental status may become evident, With Kernig’s sign, the patient is placed in the supine position.
especially in older patients. Patients may also complain of The thigh of one leg is flexed at the hip and knee to form a
photophobia. A petechial rash (resembling a rug or brush burn) 90-degree angle. Then the leg is slowly completely extended
or purpuric rash may develop (Lippincott Williams & Wilkins, at the knee joint. If the leg cannot be completely extended
2017; WHO, 2018b). because of pain, the sign is positive and meningeal irritation is
Infants may develop a bulging anterior fontanel. Children may indicated (Lippincott Williams & Wilkins, 2017).
refuse to eat or feed, have behavioral changes, exhibit arching of Onset of bacterial meningitis may take several hours or several
the back and neck, and develop seizures (Lippincott Williams & days and depends on the patient’s age, immune status, the
Wilkins, 2017). coexistence of any other medical conditions, and the causative
Patients often exhibit positive Brudzinski’s and Kernig’s signs. organism. Severe forms of the disease may progress with
startling rapidity, even leading to death in a matter of hours
(Lippincott Williams & Wilkins, 2017; WHO, 2018c).
Diagnosis
In addition to patient history and physical examination, not conclusive because they are part of the normal flora of
the following diagnostic tests are used to confirm bacterial the nasopharyngeal area.
meningitis (Lippincott Williams & Wilkins, 2017; Pagana & ● Complete blood count (CBC) with differential: Elevated
Pagana, 2018; WHO, 2018c): leukocyte count is present in bacterial meningitis.
● Blood or cerebrospinal fluid (CSF) stain: The presence of ● CSF evaluation: CSF is evaluated for elevated pressure,
gram-negative diplococci is highly suggestive for Neisseria elevated leukocytes, elevated protein, and low glucose,
meningitidis. which are suggestive of the disease.
● Blood culture, CSF culture, or culture of lesion scrapings: A ● MRI/CT scan (with and without contrast): performed to rule
positive result for the bacterium confirms diagnosis. Note out other disorders such as abscesses.
that nasopharyngeal infections positive for the bacterium are
Effective evaluation and management of bacterial meningitis edema, and anticonvulsants or sedatives to reduce restlessness
should be accomplished by a team effort with physicians, nurses, (Lippincott Williams & Wilkins, 2017).
infectious disease specialists, neurologists, internal medicine Supportive interventions include the following (Lippincott
specialists, and laboratory personnel working closely together Williams & Wilkins, 2017; WHO, 2018c):
(Lippincott Williams & Wilkins, 2017; WHO, 2018c). ● Fluid and electrolyte replacement.
The majority of patients receive high doses of intravenous ● Maintenance of a patent airway and administration of oxygen
antibiotics as soon as bacterial meningitis is suspected. Still, as needed.
cultures should be obtained before starting the antibiotic therapy. ● Bed rest.
Antibiotics used depend on the specific pathogen causing the ● Meticulous monitoring of vital signs and intake and output.
disease and whether the patient is allergic to any medications. ● Droplet precautions.
Typically, patients receive intravenous (IV) antibiotics for 2 weeks Report all cases of bacterial meningitis to public health
or longer. This is followed by oral antibiotic therapy (Lippincott authorities. Administer prophylactic antibiotics to anyone
Williams & Wilkins, 2017; WHO, 2018c). Other medications who has come into close contact with the patient. Healthcare
used as treatment measures include digoxin (Lanoxin) to control professionals who work in close contact with the patient may
arrhythmias, mannitol (Osmitrol) for the reduction of cerebral need to receive prophylactic antibiotics as well.
Vaccination
The best way to prevent meningococcal disease is by getting certain medical conditions such as HIV, or are traveling to areas
vaccinated. There are two types of meningococcal vaccines: where the disease is common such as sub-Saharan Africa (HHS.
MenACWY vaccine and MenB vaccine. gov., 2020c).
MenACWY vaccine is for preteens, teens, children, and adults People should not receive the vaccine if they have serious
who have certain health conditions. All preteens at 11 to 12 allergies of any kind or are pregnant or breastfeeding. If patients
years of age and all teens at 16 years of age may receive are ill, they may need to wait until they are feeling better before
MenACWY. The booster dose at 16 years of age provides getting the vaccine (HHS.gov., 2020c).
continued protection during the ages when they are at highest
risk CDC, 2020m; HHS.gov., 2020c). Self-Assessment Quiz Question #8
MenB vaccine is for teens and young adults 16 through 23 years
of age who may also receive MenACWYvaccine. The preferred During physical exam of an 18-year-old college student, the
ages to receive this vaccine are 16 through 18 years old. Multiple nurse flexes the patient’s head upward. The nurse notes that
doses are needed for the best protection. It is important that the the patient flexes hips and knees. This indicates:
same brand is administered for all doses (CDC, 2020m; HHS. a. A positive Kernig’s sign.
gov., 2020c). b. A normal response to flexing the head.
All preteens and teens should receive the meningococcal c. A bulging anterior fontanel.
vaccine as part of their routine vaccine schedule. Additionally, d. Possible meningeal irritation and inflammation.
the vaccine is recommended for people at increased risk for
meningococcal disease, including those who live in crowded
domiciles such as college dormitories or military barracks, have

HPV AND CERVICAL CANCER
Cervical cancer is the third most common cancer of the female the American Cancer Society (2021), about 14,480 new cases
reproductive system. Left untreated, cervical cancer may become of cervical cancer will be diagnosed in 2021 and about 4,290
invasive (Lippincott Williams & Wilkins, 2017). According to women will die from cervical cancer.
Cervical cancer and HPV
Various strains of the human papillomavirus (HPV), which is a Cervical cancer is classified as preinvasive or invasive. Preinvasive
sexually transmitted, are linked to the development of most cancer can range from minimal cervical dysplasia, meaning
cervical cancers. When the body’s immune system is exposed to the lower third of the epithelium contains abnormal cells, to
HPV, it reacts by preventing the virus from doing damage. In a carcinoma in situ, meaning the full thickness of epithelium
small percentage of people, the virus survives for years, helping contains abnormally proliferating cells. If not treated, and
to cause some cervical cells to become malignant (Mayo Clinic, depending on the specific cancer form, the disease may
2019a). progress to invasive cancer (Lippincott Williams & Wilkins, 2017).
Etiology, incidence, and pathophysiology
Cervical cancer starts with the mutation of healthy cervical cells. types, thus preventing many HPV-related cancers and cases of
These abnormal cells grow and multiply in a rapid, uncontrolled genital warts (National Cancer Institute, 2021).
fashion. Malignant cells invade nearby tissues and can break off The following are HPV-related malignancies (National Cancer
from a tumor to metastasize elsewhere in the body (Mayo Clinic, Institute, 2021):
2019a). ● Cervical cancers: Virtually all cases of cervical cancer are
The exact cause of cervical cancer is unknown, but it is certain caused by HPV, and just two types of HPV, 16 and 18, are
the HPV plays a crucial role in cervical cancer development. HPV responsible for most cases.
infection is common and most people who have the virus will not ● Anal cancer: More than 90% of anal cancers are caused by
develop cancer. Factors such as the environment and personal HPV. Anal cancer is almost twice as common in women as in
lifestyle choices influence whether cancer develops (Mayo Clinic, men.
2019a). ● Oropharyngeal cancers: The majority of these kinds of
The main types of cervical cancer are squamous cell carcinoma cancers, which develop in the throat, are caused by HPV.
and adenocarcinoma. Squamous cell carcinoma begins in the Approximately 70% of these types of cancers are caused by
squamous cells of the outer part of the cervix, which projects HPV. In the US, the number of new cases is increasing every
into the vagina. The majority of cervical cancers are squamous year, and oropharyngeal cancers are now the most common
cell cancers. Adenocarcinoma, a type of cervical cancer, starts HPV-related cancers.
in the glandular cells that line the cervical canal (Mayo Clinic, ● Penile cancers: More than 60% are caused by HPV. This is a
2019a). rare type of cancer that spreads swiftly without treatment.
Most men are older than 50 years at the time of diagnosis.
Two high-risk HPVs, HPV16 and HPV18, are responsible for About 2,000 men in the US are given a diagnosis of penile
most HPV-related cancers (National Cancer Institute, 2021). cancer.
HPV infection is common. Nearly all sexually active people are ● Vaginal cancers: About 75% are caused by HPV. Vaginal cancer
infected with HPV within months to a few years of becoming is a rare type of cancer that may be found during a routine
sexually active. About half of these infections are with a high-risk pelvic exam and Pap test.
HPV type. Both males and females can become infected with ● Vulvar cancers: Most vulvar cancers, about 70%, are caused by
HPV infections and develop HPV-related malignancies. Most HPV HPV. Another rare type of cancer, vulvar cancer, accounted for
infections do not cause cancer. The immune system is usually 0.3% in 2020. An estimated 6,120 new cases were diagnosed
able to control HPV infections so that cancer does not develop. in 2020.
HPV vaccines can prevent infection with disease-causing HPV
Risk factors
Anyone who is sexually active can get HPV infection. However, ● Having sex with someone who has had multiple sexual
there are certain risk factors that increase the possibility of partners.
infection, including the following (American Cancer Society, ● Having other sexually transmitted infections.
2020b; National Cancer Institute, 2021): ● Having a weakened immune system.
● Having multiple sexual partners. ● Smoking.
Preinvasive cervical cancer usually produces no symptoms. ● Bleeding becomes more constant.
Some patients may report a watery vaginal discharge (Lippincott ● Abdominal pain and pelvic pain that radiates to buttocks and
Williams & Wilkins, 2017; Mayo Clinic, 2019a). legs.
Early invasive cervical cancer causes postcoital bleeding and ● Leakage of urine and feces from the vagina because of
pain, irregular vaginal bleeding, spotting between periods or fistula.
after menopause, and foul-smelling vaginal discharge (Lippincott ● Anorexia.
Williams & Wilkins, 2017; Mayo Clinic, 2019a). ● Weight loss.
● Anemia.
As the disease progresses and becomes more advanced, the ● Edema of the lower extremities.
following signs and symptoms are reported (Lippincott Williams
& Wilkins, 2017; Mayo Clinic, 2019a):
Diagnosis
A Pap test can detect cervical cancer before the patient and histologic examination findings confirm diagnosis (Lippincott
develops signs and symptoms. The HPV DNA test is used for Williams & Wilkins, 2017; Mayo Clinic, 2019a).
women older than 30 who have had abnormal PAP tests. Biopsy
Staging
Treatment depends on accurate disease staging. Following are Stage I: Cancer has spread from the cervix lining into the
the stages of cervical cancer (Cancer.net, 2019): deeper tissue but is still found only in the uterus.

Stage II: The cancer has spread beyond the uterus to Stage IVA: The cancer has spread to the bladder or the
nearby areas such as the vagina or tissue near the cervix, rectum, but it has not spread to other parts of the body.
but it is still inside the pelvic area. It has not spread to other Stage IVB: The cancer has spread to other parts of the
parts of the body. body.
Stage III: The tumor involves the lower third of the vagina Recurrent: Recurrent cancer is cancer that has come back
or has spread to the pelvic wall and causes hydronephrosis after treatment.
(swelling of the kidney), stops a kidney from functioning, or
involves regional lymph nodes. There is no distant spread.
Early cervical cancer is usually treated with surgery. The type of With vaginal hysterectomy the uterus is removed through the
surgery depends on the size of the cancer, its stage, and if future vagina. This approach, however, does not allow the surgeon a
pregnancy is hoped for (Mayo Clinic, 2019a). complete full view of the surrounding organs (Johns Hopkins
Surgical Options Medicine, n.d.).
Following are some surgical approaches that can be used in the With robotic-assisted radical total laparoscopic hysterectomy,
treatment of cervical cancer. using a robotic platform, the surgeon has a complete view of
For very small cervical cancers, there is a possibility that a cone the surrounding organs and more precise control over incisions
biopsy may remove the cancer entirely. A cone-shaped portion (Johns Hopkins Medicine, n.d.).
of the affected cervical tissue is removed, leaving the remainder With laparoscopic-assisted total laparoscopic hysterectomy,
of the cervix intact. This option may make pregnancy possible in the intra-abdominal portion of the operation is performed with
the future (Mayo Clinic, 2019a). the laparoscope. The remainder of the operation is performed
Trachelectomy is a possible treatment for early-stage cervical through a vaginal incision for the removal of cervical tissue
cancer. This procedure involves removing the cervix and some (Johns Hopkins Medicine, n.d.).
surrounding tissue. The uterus remains, thus allowing for the Total laparoscopic hysterectomy is done using the laparoscope.
possibility of pregnancy (Mayo Clinic, 2019a). The surgical specimen is removed via the vagina (Johns Hopkins
Radical hysterectomy involves removal of the cervix, uterus, part Medicine, n.d.).
of the vagina, and nearby lymph nodes via a large incision. This The nurse needs to be able to reinforce explanations of the
type of hysterectomy can cure early-stage cervical cancer and procedure and offer emotional support at what must be a very
prevent recurrence. Because the uterus is removed, there is no difficult time for patients and families. Instructions about the
possibility of pregnancy (Johns Hopkins Medicine, n.d.; Mayo signs and symptoms of infection and the importance of early
Clinic, 2019a). ambulation is imperative.
Radiation
Radiation is often combined with chemotherapy for the affected area of the body. Internally, a device containing
treatment of locally advanced cervical cancers and in the case radioactive material is inserted into the vagina, usually for only
of increased risk of recurrence. Radiation can be delivered a few minutes. This is referred to as brachytherapy (Mayo Clinic,
externally by directing an external beam of radiation to the 2019a).
Chemotherapy
Chemotherapy may be administered parenterally or orally. advanced cervical cancer. For significantly advanced cancer, high
Sometimes both methods are used. Low doses of chemotherapy, doses of chemotherapy may be administered to help control
often given in conjunction with radiation, may be used for locally symptoms (Johns Hopkins Medicine, n.d.).
Palliative care
Palliative care focuses on pain relief, control of other symptoms, palliative care in conjunction with other treatments patients may
and emotional support for patients and families. The entire receive (Johns Hopkins Medicine n. d.).
team works together to improve quality of life as they provide
Preventive measures
Women can take a number of steps to prevent cervical cancer. ● Women who have had a total hysterectomy should stop
Nurses should advise patients not to smoke or to stop smoking. screening such as Pap tests and HPV tests unless the
HPV vaccine is critical for female and male teens. Nurses hysterectomy was done as a treatment for cervical cancer
should inform patients that delaying the first sexual intercourse or serious precancer. Women who have had a hysterectomy
experience may help reduce risk of the disease, and that having without removal of the cervix (called a supracervical
fewer sexual partners may also decrease risk (Lippincott Williams hysterectomy) should continue cervical cancer screening
& Wilkins, 2017; Mayo Clinic, 2019a). Patients that identify sexual according to the guidelines above.
partners can help stop the spread of the disease. ● People who have been vaccinated against HPV should still
Females should have routine Pap test screenings according to follow these guidelines for their age groups.
the following guidelines (American Cancer Society, 2020b): ● Patients who have a history of a serious precancer should
● Cervical cancer testing (screening) should begin at age 25 or continue to have testing for at least 25 years after that
earlier depending on the sexual history. condition was found, even if the testing goes past age 65.
● Those aged 25 to 65 should have a primary HPV test every 5 ● Those who are at high risk of cervical cancer because of a
years. If primary HPV testing is not available, screening may suppressed immune system (for example from HIV infection,
be done with either a co-test that combines an HPV test with organ transplant, or long-term steroid use) or because they
a Pap test every 5 years or a Pap test alone every 3 years. were exposed to DES in utero, may need to be screened
● A primary HPV test is an HPV test that is done by itself for more often. Diethylstilbestrol (DES) is a synthetic form of the
screening. FDA has approved certain tests to be primary HPV female hormone estrogen. It was prescribed to pregnant
tests. women between 1940 and 1971 to prevent miscarriage,
● Those over age 65 who have had regular screening in the premature labor, and related complications of pregnancy, but
past 10 years with normal results and no history of CIN2 or it is no longer used during pregnancy. They should follow the
more serious diagnosis within the past 25 years should stop recommendations of their healthcare team.
cervical cancer screening. Once stopped it should not be
started again.

Vaccination
Up to 70% of HPV-related cervical cancer cases can be ● Two doses of HPV vaccine are recommended for most
prevented with vaccination. Various changes have been made persons starting the series before their 15th birthday. The
within the past few years. Patients younger than 15 need only second dose of HPV vaccine should be given up to 12
two rather than three doses. The vaccine itself can be used in months after the first dose.
adults up to the age of 45. Only 9-valent HPV vaccine (Gardasil ● Adolescents who receive two doses less than 5 months apart
R9) has been available in the US since late 2016 (CDC, 2020a; will require a third dose of HPV vaccine.
CDC, 2020x; Cleveland Clinic, 2019). ● Three doses of HPV vaccine are recommended for teens
The 9-valent HPV vaccine protects against HPV 16 and 18, HPV and young adults who start the series at ages 15 through
types that cause about 66% of cervical cancers and the majority 26 years and for immunocompromised persons. The
of other HPV- attributable cancers in the US, and five additional recommended three-dose schedule is younger than 1 year, 1
cancer-causing types, which account for about 15% of cervical to 2 months, and 6 months. Three doses are recommended
cancers. It also protects against HPV 6 and 11, HPV types that for immunocompromised persons, including those with HIV
cause most anogenital warts (CDC, 2020a). infection aged 9 through 26 years.
HPV vaccine recommendations and important points include the
following (CDC, 2020a; Cleveland Clinic, 2019):
● HPV vaccine is recommended for routine vaccination at age What advice should be given to 60-year-old women regarding
11 or 12 years, but vaccination can be started at age 9. cervical cancer screening?
● Vaccination should be for all persons through the age of 26
years. However, some adults ages 27 through 45 years may a. If she has no history of cervical abnormalities, she can stop
receive the vaccine based on discussion with their healthcare screening.
providers or if they did not get adequately vaccinated when b. If she has been vaccinated against HPV, she can discontinue
they were younger. It is important to note that, for people screening.
aged 27 to 45 years, vaccination provides less benefit for c. If she has had a serious precancer, she should continue to
a variety of reasons, including that more people in the age have testing for at least 25 years.
group have already been exposed to HPV. d. If she has a suppressed immune system, screening should
● HPV vaccine is not recommended for use during pregnancy. not be performed until the immune system is functioning
normally.
VACCINE-PREVENTABLE DISEASES: ROTAVIRUS
Before vaccine development, rotavirus caused the following on Rotavirus was the leading cause of severe diarrhea in infants
a yearly basis in children under 5 years of age in the US (CDC, and young children in the US before the rotavirus vaccine was
2019h): introduced in 2006 (CDC, 2019h). Adults can also be infected
● More than 400,000 visits to physicians. and may be at increased risk if other chronic conditions are
● More than 200,000 emergency department visits. 55,000 to present.
70,000 hospitalizations.
● 20 to 60 deaths.
Risk factors
The most severe cases of rotavirus disease occur primarily Older adults have a greater risk of contracting the disease,
among unvaccinated children ages 3 months to 3 years. Children as do those who provide care to children who have rotavirus
at greatest risk for contracting rotavirus disease are those who disease, have a compromised immune system, or are traveling to
are in childcare settings. They are more likely to get rotavirus in geographic regions where the disease is present (CDC, 2018d;
the winter and spring (January through June; CDC, 2019g). CDC, 2019g).
Complications
Complications associated with rotavirus infection include with surfaces and objects contaminated by the virus (CDC,
severe dehydration, shock, and skin breakdown (CDC, 2019g). 2019g).
Transmission and Pathophysiology Infected patients pass billions of rotavirus particles in their stools.
The disease is transmitted primarily through the fecal-oral route, It takes only a small number of such particles to cause infection.
although there have been reported low titers of the virus in For example, babies or small children can touch contaminated
respiratory tract secretions and other body fluids. Transmission objects, put their fingers in their mouths, and become infected
may occur by ingesting contaminated water or food and contact (CDC, 2019g). Strict handwashing should be carried out by those
who care for young children or older persons with diarrhea.
After an incubation period of 1 to 3 days, signs and symptoms mild to severe, and it usually lasts from about 3 to 9 days (CDC,
develop, including fever; nausea; vomiting; and profuse, watery, 2019g).
nonfoul-smelling diarrhea. Effects of the disease can range from
Diagnosis
Diagnosis is confirmed by rapid antigen detection of rotavirus in ● Overfeeding.
feces. Acute diarrhea may also be caused by bacteria, parasites, ● Irritable bowel syndrome.
side effects of antibiotic therapy, and food poisoning (CDC, ● Celiac disease.
2019g). ● Lactose intolerance.
Signs and symptoms similar to those of rotavirus may also be ● Cystic fibrosis.
caused by the following (CDC, 2019g): ● Inflammatory bowel syndrome.

In otherwise healthy patients, rotavirus is usually a self-limiting electrolyte replacement and rest (CDC, 2019g; Meadows-Oliver,
illness and lasts only a few days without serious complications. 2019).
Treatment focuses on supportive interventions such as fluid and

Patients, especially infants and young children, should be carefully Parents and other caregivers should be instructed to wash hands
monitored for signs of dehydration such as extreme fussiness after touching patients’ body fluids, clean objects that have been
or sleepiness in infants and children; irritability and confusion in contact with body fluids such as toys bed linens, and clean
in adults; very dry mouth, skin, and mucus membranes; greatly perineum gently and thoroughly to avoid skin breakdown (CDC,
reduced urinary output; concentrated urine; sunken eyes; and 2019g; Meadows-Oliver, 2019.
dizziness (CDC, 2019g; Meadows-Oliver, 2019).
Vaccination
Incidence of the disease has also decreased among older There are two FDA-approved rotavirus vaccines in the US:
children and adults who have not been vaccinated. Vaccinated RotaTeq and Rotarix. They are liquids and administered orally.
children are less likely to contract the disease and transmit it to RotaTeq is given in a three-dose series at ages 2, 4, and 6
others (CDC, 2019g). Day care facilities often require vaccination months. Rotarix is administered in a two-dose series, with doses
of children to prevent the spread of rotavirus. given at ages 2 and 4 months (CDC, 2018d; CDC, 2019g;
Meadows-Oliver, 2019).
PNEUMONIA
Pneumonia is an acute inflammatory infection of the lungs that ● Location in the lung: Lobular pneumonia affects part or
involves the terminal airways and alveoli of the lung. Pneumonia parts of a lobe. Lobar pneumonia affects an entire lobe, and
is classified according to the pathogens that cause the disease bronchopneumonia affects the distal airways.
and the specific location of involvement (CDC, 2019f; Lippincott ● Type: Primary pneumonia is caused by inhalation or
Williams & Wilkins, 2017). aspiration of a pathogen; secondary pneumonia may
For example, pneumonia can be classified according to the follow lung damage caused by a noxious chemical or
following (CDC, 2019f; Lippincott Williams & Wilkins, 2017; superinfection.
Mayo Clinic, 2020e).): For the purpose of this education program, which focuses on
● Pathogen: Pneumonia can be caused by viral, bacterial, vaccine-preventable diseases, the emphasis is on pneumococcal
fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial pneumonia. This type of pneumonia is caused by a group of
pathogens. bacteria called Streptococcus pneumonia. This type can cause
not only pneumonia, but also meningitis (Mayo Clinic, 2020e).
Risk factors
Following are the risk factors for developing pneumonia ● Prolonged immobility or bedrest.
(Lippincott Williams & Wilkins, 2017; Mayo Clinic, 2020e): ● Chronic illness.
● Smoking. ● Cancer, especially lung cancer.
● Alcoholism. ● Malnutrition.
● Bronchial asthma. ● Sickle cell disease.
● Immunosuppression. ● Aspiration.
● Cardiac or respiratory disease. ● Immunosuppressive therapy.
● Advanced age. ● Exposure to noxious gases.
Complications
Complications associated with pneumonia include the following ● Lung abscess.
(Lippincott Williams & Wilkins, 2017; Mayo Clinic, 2020e): ● Pericarditis.
● Atelectasis. ● Persistent hypotension and shock, especially in elderly
● Bacteremia. patients with gram-negative bacterial disease.
● Delirium. ● Pleural effusion.
● Empyema. ● Respiratory failure.
● Endocarditis. ● Septic shock.
● Hypoxemia. ● Superinfections such as meningitis and pericarditis.
Pneumococcal pneumonia is often preceded by an upper ● Crackles (rales).
respiratory tract infection. Following are the signs and symptoms ● Cough.
of pneumococcal pneumonia (Lippincott Williams & Wilkins, ● Production of sputum.
2017; Mayo Clinic, 2020e): ● Pleuritic chest pain exacerbated by coughing.
● Abrupt onset of severe shaking chills. ● Dyspnea.Tachycardia.(Use of accessory muscles of respiration
● Sustained temperature of 102°F to 104°F. and nasal flaring.)
● Tachypnea.
Diagnosis
Diagnosis is made by a thorough history and physical ● Blood cultures: Obtained to detect and identify bacteria and
examination and the following diagnostic tests (Lippincott other pathogens.
Williams & Wilkins, 2017; Mayo Clinic, 2020e): ● White blood cell count (WBC): Elevated in the presence of
● Chest X-ray: Shows infiltrate and the location and extent of infection.
the disease. ● Immunologic testing: Such tests detect microbial antigens in
● Sputum evaluation: Gram stain and culture and sensitivity of serum, sputum, and urine.
sputum are performed to identify the causative pathogen.
Antibiotic treatment depends on the causative agents and include oxygen therapy, frequent coughing exercises and deep
local antibiotic resistance. Antibiotic therapy begins as soon breathing, frequent position changes, and as much mobility as
as possible after taking the appropriate cultures. It is not possible (Lippincott Williams & Wilkins, 2017).
necessary to wait for results as long as cultures are obtained
before administering the medication (Lippincott Williams &
Wilkins, 2017; Mayo Clinic, 2020e). Additional interventions

Prevention
Nurses should encourage all patients, especially those who expectoration. Early ambulation is encouraged postoperatively.
have limited mobility, to perform deep breathing and coughing For patients who spend a lot of time in bed, encourage position
exercises frequently. Incentive spirometers are used to changes and range of motion exercises (Lippincott Williams &
encourage prolonged inspiration to increase lung expansion and Wilkins, 2017; Mayo Clinic, 2020e).
Vaccination
Vaccines help prevent pneumococcal disease, which is any For adults 65 years or older who do not have an
illness caused by Streptococcus pneumoniae bacteria (Mayo immunocompromising condition, cerebrospinal fluid leak, or
Clinic, 2019b). CDC recommends routine administration of cochlear implant and want to receive PCV13 and PPSV23,
pneumococcal conjugate vaccine (PCV13) for all children administer one dose of PCV13 first and then give one dose of
younger than 2 years of age. PCV13 is given to infants as a PPSV23 at least 1 year later. If the patient has already received
series of four doses, one dose at each at 2 months, 4 months, PPSV23, give the dose of PCV13 at least 1 year after they have
6 months, and 12 through 15 months. Children who miss their received the most recent dose of PPSV23. Anyone who has
shots or start the series later should still get the vaccine. The received any doses of PPSV23 before age 65 should receive
number of doses recommended and the intervals between one final dose of the vaccine at age 65 or older. Administer
doses will depend on the child’s age when vaccination begins this last dose at least 5 years after the prior PPSV23 dose.
(CDC, 2019n). Routine administration of pneumococcal polysaccharide vaccine
For adults 65 years or older who do not have an (PPSV23) is recommended for all adults 65 years or older. In
immunocompromising condition, cerebrospinal fluid leak, or addition, CDC recommends PCV13 based on shared clinical
cochlear implant and want to receive PPSV23 only, administer decision making for adults 65 years or older who do not have
one dose of PPSV23. Anyone who received any doses of PPSV23 an immunocompromising condition, cerebrospinal fluid leak,
before age 65 should receive one final dose of the vaccine at or cochlear implant and have never received a dose of PCV13.
age 65 or older. Administer this last dose at least 5 years after Clinicians should consider discussing PCV13 vaccination with
the prior PPSV23 dose (CDC, 2019n). these patients to decide if vaccination might be appropriate
(CDC, 2019n).
INFLUENZAE (HIB)
Haemophilus influenzae type b (Hib) is a type of bacterium from colonization. Although the exact method of infection is not
that can affect many organ systems. The most common types known, the bacteria can invade the bloodstream and spread to
of disease caused by Hib bacteria are pneumonia, bacteremia, distant sites in the body, such as the meninges of the central
meningitis, epiglottis, septic arthritis, cellulitis, otitis media, and nervous system (CDC, 2020f).
purulent pericarditis. An estimated 3% to 6% of Hib infections In the pre-vaccine era, meningitis was the most common
in children are fatal. Patients 65 and older infected with invasive manifestation of invasive Haemophilus influenzae type b.
H. influenzae have higher case-fatality rates than children have Patients present with decreased mental status, stiff neck,
(CDC, 2020f). fever, hearing impairment, and other neurologic symptoms.
Haemophilus influenzae enters the body through the respiratory Because Hib can affect many organ systems, other common
tract and replicates in the nasopharynx. It can colonize the manifestations include pneumonia, arthritis, cellulitis, and
nasopharynx temporarily or for several months. Many patients epiglottitis. Hib can also cause osteomyelitis and pericarditis
do not develop symptoms in response to colonization and can (CDC, 2020f).
develop immunity. Some patients can develop invasive infections
Risk factors
According to CDC (2020f), those at increased risk of Hib disease ● Adults who are 65 and older.
are unimmunized children younger than 5 years old, household ● Native Americans and Alaska Natives.
contacts of a person with the disease, and day care classmates of ● People with sickle cell disease, asplenia (absence of
a person with the disease. a spleen), HIV, and immunoglobulin and complement
Additionally, the following groups are at increased risk of H. component deficiencies.
influenzae disease (CDC, 2020f): ● People with malignant neoplasms requiring hematopoietic
● Children younger than 5 years of age. stem cell transplant, chemotherapy, or radiation therapy.
Haemophilus influenzae type b generally sparks a characteristic purulent exudate; and mucosal edema. If it spreads to the lungs,
inflammatory response in the affected tissues and causes a high it can cause bronchopneumonia. In the pharynx it can cause
fever and general malaise. When it infects the larynx, trachea, epiglottitis, as well as reddened pharyngeal mucosa and, rarely,
or bronchial tree, it causes an irritable cough; dyspnea; a thick, a soft yellow exudate (CDC, 2020f).
Complications
Complications associated with Hib include the following ● Cellulitis.
(CDC, 2020f): ● Respiratory failure.
● Meningitis. ● Subdural effusions.
● Pleural effusion. ● Obstruction of the upper airways.
● Pericarditis. ● Neurologic sequelae that can be permanent.
Invasive disease caused by Haemophilus influenzae type b Children with serious illness are hospitalized with contact and
generally requires hospitalization. The antibiotic used depends respiratory isolation for 24 hours after starting antibiotics.
on the site of infection and susceptibility testing. In the US, Maintain respiratory function through proper positioning,
many forms of the bacteria produce beta-lactamase; more than humidification, and suctioning if necessary. Monitor patients for
50% are resistant to ampicillin. For the treatment of invasive signs of cyanosis and dyspnea, which could indicate the need for
illness, cefotaxime or ceftriaxone is recommended. For infections intubation. Monitor patients for signs of dehydration, including
that are not as serious, oral cephalosporins (except for first- decreased urine output, increased pulse, decreased skin turgor,
generation cephalosporins such as cephalexin) are usually and parched lips. Encourage rest (Merck Manual Professional
effective (Merck Manual Professional Version, 2020). Version, 2020).

Prevention
After initiation of vaccine therapy, serious cases of Hib disease The majority of people over the age of 5 do not need the Hib
have dropped by more than 99% since 1991. There are two types vaccine. However, they may need to receive the vaccine if they
of Hib vaccines: Hib vaccine, which protects children and adults; have a damaged spleen or sickle cell disease or have had a bone
and the DtaP-IPV vaccine, which protects babies ages 2 through marrow transplant (HHS.gov., 2020b).
18 months from Hib disease, tetanus, diphtheria, whooping People who should not receive the Hib vaccine include infants
cough, and polio (HHS.gov., 2020b). younger than six weeks, those who have had a life-threatening
Infants and children need three or four doses depending on which reaction to the vaccine in the past, and people who have a serious
brand of the vaccine they receive. Children should receive doses allergy to any of the vaccine’s ingredients (HHS.gov., 2020b).
of the vaccine according to the following schedule (HHS.gov.,
2020b): Self-Assessment Quiz Question #10
● 2 months of age for the first dose.
● 4 months of age for the second dose. All of the following actions are appropriate for the prevention
● 6 months of age for the third dose if they are getting four of Hib disease EXCEPT:
doses. a. Administer the first dose of Hib vaccine with 1 week of birth.
● 12 through 15 months for the booster (additional dose).
b. Explain to parents that most people over the age of 5 do
Children ages 2 through 18 months may also receive a not need the Hib vaccine.
combination vaccine that is designed to protect against Hib c. Administer the DtaP-IPV vaccine to babies ages 2 through
disease, tetanus, diphtheria, whooping cough, and polio (DtaP- 18 months.
IPV/Hib). The child’s healthcare providers can recommend the d. Explain to parents that children should receive three or four
vaccine that is appropriate (HHS.gov., 2020b). doses depending on which brand of the vaccine is being
administering.
Nicholas and his family were enjoying a family vacation at their which the raccoon ran rapidly into the woods. Nicholas and his
favorite campground. One afternoon, as they hiked a familiar family drove to the nearest hospital emergency department
wooded trail, they came upon a raccoon. The animal was immediately after informing campground authorities of the
unsteady on its feet, growling, and drooling profusely. Alarmed, incident. The raccoon could not be located and hospital
Nicholas stepped between the raccoon and his young daughter. personnel believed that, based on the behavior of the animal, it
The animal charged Nicholas and bit him on the leg, after was advisable to initiate treatment with rabies vaccine.
RABIES
Although not a disease for which vaccine is routinely for a disease that is serious and virtually 100% fatal (WHO,
administered, rabies vaccine is one of the few treatment options 2020e).
Rabies is a preventable disease affecting mammals. It is most Rabies is found on all continents with the exception of
frequently transmitted via the bite of a rabid animal. Any Antarctica. More than 95% of human deaths from rabies occur in
mammal can transmit the rabies virus. In the US, most rabies Asia and Africa. Rabies in poor, vulnerable populations may go
cases reported to CDC occur in wild animals like bats, foxes, undiagnosed or unreported. It occurs most often in remote rural
skunks, and raccoons. In the developing countries of Africa and communities where dog vaccination programs have not been
Southeast Asia, stray dogs are the most likely animals to transmit implemented (WHO, 2020f). Domestic pets such as dogs and
rabies to people (CDC, 2020p; Mayo Clinic, 2019c; WHO, cats are usually required by state laws to be vaccinated.
2020e). According to WHO, 40% of people bitten by suspected rabid
The rabies virus is usually transmitted by direct contact with animals are children under the age of 15. Dog bites are the
virus-laden saliva of a rabid animal through a bite or a scratch. source of the majority of human rabies deaths. Dog bites
Rarely, the rabies virus is transmitted via routes such as mucous contribute up to 99% of all rabies transmissions to humans.
membranes, aerosol transmission, and corneal and organ Cleansing the wound/bite with soap and water and receiving
transplantations (CDC, 2020p). immunization within a few hours after contact with a suspect
The virus replicates in the striated muscle cells at the site of entry rabid animal can prevent the onset of rabies and death. More
and spreads up the nerves to the CNS, where it replicates in than 29 million people throughout the world receive a post-bite
the brain. The disease is nearly always fatal if patients begin to vaccination. The economic burden of dog-mediated rabies is
show signs and symptoms. Thus, anyone who may have a risk of about $8.6 billion per year (WHO, 2020e).
contracting rabies should receive rabies vaccines (Mayo Clinic,
2019c).
The incubation period of rabies virus is usually about 2 to 3 With furious rabies, patients exhibit hyperactivity, excited
months but varies from as little as less than 1 week to more than behavior, and hydrophobia. Death occurs within a few days from
1 year, depending on factors such as virus entry and viral load cardiopulmonary arrest.
(WHO, 2020e). Paralytic rabies is responsible for about 20% of the total number
Initial symptoms include fever; malaise; fatigue; headache; of human cases of rabies. This form produces less dramatic signs
a sense of apprehension and anxiety; and pain or unusual and symptoms, and the course is usually longer than the furious
sensations of tingling, pricking, or burning at the site of the bite. form. Muscle paralysis occurs gradually, beginning at the site
As the virus spreads to the CNS, symptoms of excitation – such of the wound. Coma develops slowly and eventually leads to
as agitation, restlessness, anxiety, and cranial nerve dysfunction – death. The paralytic form of rabies is often misdiagnosed. This
develop (WHO, 2020e). contributes to under-reporting of the disease and the lack of
As the disease advances and the virus spreads through the CNS, accurate statistics pertaining to prevalence and incidence.
progressive fatal inflammation of the CNS develops. At this
point, two clinical forms of the disease can occur: furious rabies
and paralytic rabies (WHO, 2020e).

Diagnosis
Diagnosis is confirmed when the virus is isolated from the prophylaxis. Laboratory tests may spare patients from stress and
patient’s saliva or throat and with an examination of the psychological trauma and being given vaccine if the animal is
blood by direct fluorescent antibody (DFA). A swift diagnosis not rabid (CDC, 2020p).
is critical for the prompt administration of postexposure
Because rabies is fatal unless treatment is administered promptly, For those people who have already had the rabies vaccine, two
all people who have sustained unprovoked animal bites should doses are administered. The first dose is administered as soon
be treated as though rabies were suspected (WHO, 2020e). as possible and the second dose is given 3 days later. The rabies
immune globulin injection is not needed (HHS.gov., 2020e).
Nursing consideration: As part of their public health
Common side effects of the rabies vaccine may go away as the
initiatives, nurses must be sure to teach patients about the
patient’s body adjusts to the vaccine. These side effects should
ongoing danger of rabies and steps to avoid contracting
be reported to the patient’s healthcare professional and their
the disease. They must also teach the necessity of getting
severity discussed. Following are common side effects (HHS.
immediate medical attention if anyone is exposed to an
gov., 2020e):
animal bite, especially a wild animal’s.
● Chills.
Postexposure prophylaxis (PEP) is the immediate treatment of a ● Fever.
bite victim after rabies exposure. Initial first aid for animal bites is ● Dizziness.
washing and flushing the wound immediately for a minimum of ● General discomfort or feeling ill.
15 minutes with soap and water, detergent, povidone iodine, or ● Headache.
other substances that kill the rabies virus (WHO, 2020e). ● Itching, pain, redness or swelling at the injection site.
● Nausea
Depending on the severity of contact with the suspected rabid ● Stomach, abdominal pain.
animal, a full PEP course is recommended as follows (WHO, ● Muscle and joint aches and pains.
2020e):
Category I: touching or feeding animals, animal licks on intact Side effects such as the following are less common but require
skin (no exposure). immediate medical attention (HHS.gov., 2020e):
● Chest tightness.
Category II: nibbling of uncovered skin, minor scratches or ● Confusion.
abrasions without bleeding (exposure). ● Crawling, burning, itching, numbness, tingling feelings, or
Category III: single or multiple transdermal bites or scratches, “pins and needles” sensations.
contamination of mucous membrane or broken skin with saliva ● Coughing.
from animal licks, exposures to direct contact with bats (severe ● Difficulty moving.
exposure). ● Hives.
All Category II and III exposures are assessed as carrying a risk of ● Irritability.
developing rabies and require PEP. This risk is increased if (WHO, ● Joint inflammation.
2020e): ● Loss of strength.
● The biting mammal is a known rabies reservoir or vector ● Lymphadenopathy in the neck, underarm, or groin.
species. ● Muscle pain, stiffness, or weakness.
● The exposure occurs in a geographical area where rabies is ● Paralysis or severe weakness in the legs.
still present. ● Rash.
● The animal looks sick or displays abnormal behavior. ● Respiratory distress.
● A wound or mucous membrane was contaminated by the ● Seizures.
animal’s saliva. ● Stiffness of the extremities or neck.
● The bite was unprovoked. ● Swelling of the eyelids, area around the eyes, face, lips, or
● The animal has not been vaccinated, or vaccination status tongue.
cannot be determined. ● Tachycardia.
● Trouble swallowing.
● Unusual fatigue.
Nursing consideration: The vaccination status of the suspect ● Vomiting.
animal should not be the deciding factor when considering
to initiate PEP when the vaccination status of the animal
is questionable. This can be the case if dog vaccination Self-Assessment Quiz Question #11
programs are not sufficiently regulated or followed out of lack A patient has experienced a Category II contact with a
of resources or low priority (WHO, 2020e). suspected rabid animal. Which of the following statements
If someone has never had the rabies vaccine, the first dose about this type of contact is accurate?
should be administered as soon as possible. The next dose is a. There was no exposure, so no vaccine is necessary.
given 3 days after the first dose. The third dose is given 1 week b. There was contamination of mucous membrane.
after the first dose. The last dose is given 2 weeks after the first c. The vaccination status of the suspect animal will determine
dose (HHS.gov., 2020e). treatment.
A dose of rabies immune globulin is administered with the first d. A dose of vaccine should be administered as soon as
dose of the vaccine as well. For those with weakened immune possible.
systems, another dose is given 4 weeks after the first dose (HHS.
gov., 2020e).
ANTHRAX
The FBI announced that it has concluded its investigation into that a single spore-batch created and maintained by Dr. Bruce
the 2001 anthrax mailings, saying Friday that a biodefense E. Ivins at the United States Army Medical Research Institute of
researcher carried out the attacks alone. The anthrax letters Infectious Diseases was the parent material for the letter spores,
killed five people and sickened 17 shortly after the September said a report released Friday by the FBI. Evidence developed
11, 2001, terrorist attacks. The letters, filled with bacterial from that investigation established that Dr. Ivins, alone, mailed
spores, were sent to Senate Democratic leaders and news the anthrax letters. Ivins, 62, committed suicide in July 2008 as
organizations. By 2007 investigators conclusively determined

federal agents were closing in on him, police said. (CNN Justice, that quickly develops a black sore. Some people develop
2010) muscle aches, headaches, fever, and vomiting. It is essential
Like rabies, immunization for anthrax prevention is not routinely that cutaneous anthrax be treated quickly. The mortality
administered. But the use of anthrax as a terrorist weapon makes rate for cutaneous anthrax is about 20% without antibiotic
it important for healthcare workers to become familiar with its therapy.
clinical manifestations and available vaccine. 2. Gastrointestinal (GI) anthrax: GI anthrax is acquired from
eating the meat of an infected animal. Patients develop
Anthrax is an acute bacterial infection caused by the bacterium symptoms similar to food poisoning such as nausea,
Bacillus anthracis, which exists as spores in soil. These spores can vomiting, and fever. These symptoms progress to abdominal
live for years. It is most often found in animals that graze such pain, vomiting blood, and severe diarrhea. People should
as sheep, goats, cattle, and horses. The disease can also affect seek medical evaluation and treatment swiftly. Even with
humans who come into contact with infected animals or their fur, treatment, death occurs in 25% to 75% of cases.
bones, hair, or wool. Anthrax is also used as a bioterrorism agent, 3. Inhalation anthrax: Inhalation anthrax is the most serious
as in the 2001 case when letters containing anthrax spores were form of the disease. It is also the rarest form. People
mailed to various people, including members of Congress and contract inhalation anthrax by breathing in a large number
news organizations in the US (FDA, 2018; WHO, 2020b). of anthrax spores that have been suspended in the air. Initial
There are three forms of anthrax (FDA, 2018; WHO, 2020b). signs and symptoms resemble those of the common cold:
1. Cutaneous or skin anthrax: This form is usually transmitted malaise, fever, headache, chills, and myalgia. The disease
when someone with a break in their skin comes into direct can progress to cause severe respiratory distress and shock.
contact with anthrax spores. It is the most common form of Sadly, even with treatment, inhalation anthrax is usually fatal,
anthrax in humans and is responsible for more than 95% of with a fatality rate of 80% or higher.
reported cases. The point of contact results in an itchy bump
Diagnosis
Diagnosis is made by culturing the patient’s blood, skin lesions, diagnosis of anthrax. Specific antibodies to the bacterium may
or sputum. The presence of Bacillus anthracis confirms the also be detected (Cleveland Clinic, 2020).
Treatment and nursing consideration
It is imperative to initiate treatment as soon as anthrax exposure Emotional support is also critical because this is a frightening,
is suspected. Antibiotic therapy with agents such as penicillin, often fatal, disease.
ciprofloxacin, and doxycycline is most often used. Monitor the Standard precautions must be strictly implemented and surfaces
patient’s response to antibiotic therapy and perform supportive in the patient’s room disinfected. Initiate contact precautions if
measures such as monitoring vital signs, intake and output, patients have draining lesion (Cleveland Clinic, 2020).
and cardiac and respiratory status (FDA, 2018; WHO, 2020d).
Vaccine
Anthrax vaccine consists of an attenuated strain of the who is no longer at the home or workplace, have no return
bacterium. This vaccine is not available for routine administration address or a return address that does not seem to be
to the general public and is, as of this writing, administered legitimate, are of unusual weight given their size, are oddly
only to US military personnel before deployment and, under shaped, have an unusual amount of tape, have strange odors
certain circumstances, to other people who have been or may be or stains, or are marked with restrictive instructions such as
exposed to anthrax (FDA, 2018; WHO, 2020b). confidential or personal.
The only licensed anthrax vaccine is anthrax vaccine adsorbed ● People who receive suspicious letters or parcels should not
(AVA), or BioThraxTM, and is indicated for active immunization handle them. They should move the letters or parcels to
for the prevention of anthrax caused by Bacillus anthracis in an isolated area. Everyone who has touched the letters or
people ages 18 to 65 who are at high risk of exposure, such as parcels should wash their hands with soap and water.
people who work with potentially infected animals, researchers ● Law enforcement authorities should be notified immediately
who study the bacterium, or military personnel. The vaccine has of any suspected source. A list of all people who have
been approved for use since 1970. Next- generation vaccines touched the letter or parcel, including their contact
are currently under development by a variety of manufacturers information, should be compiled and given to law
(FDA, 2018). enforcement authorities.
● All items of clothing worn when in contact with the suspicious
BioThraxTM has been purchased by the US federal government. letters or parcels should be placed in plastic bags and given
It is stored in the Strategic National Stockpile (SNS) for use to law enforcement authorities. As soon as possible, all
as part of a postexposure prophylaxis regimen with licensed people who have had contact with the suspicious letters or
antibiotics in the event of a terrorist attack with anthrax. The parcels should shower with soap and water. Notify public
military also has an active vaccination program for military health officials.
personnel going to specific locations around the world (FDA,
2018).
Questions still exist about the spread of anthrax via the mail
because this was the mode of transport in the 2001 domestic When discussing anthrax with patients, which of the following
terrorist attacks. WHO (2020b) offers the following information information is accurate?
about suspicious letters or parcels: a. Inhalation anthrax is the most serious form of the disease.
● Examples of characteristics of letters or parcels that should b. Anthrax spores die quickly.
incite suspicion include having a powdery substance on c. Anthrax cannot be acquired from eating infected meat.
the outside, are unexpected, are from someone who is
d. Several licensed anthrax vaccines are available.
unfamiliar, have incorrect titles or titles with no name, contain
misspellings of common words, are addressed to someone
COVID-19
The coronavirus disease 2019 (COVID-19) pandemic is caused Many questions about the virus, mutations, transmission, and
by the novel severe acute respiratory syndrome coronavirus 2 treatment remain. The following information is current as of this
(SARS-CoV-2). This novel virus is found throughout the world, writing (March 2021).
causing an abrupt increase in hospitalizations for pneumonia
with multiorgan disease (Wiersinga et al., 2019).

Transmission
COVID-19 was first documented in Wuhan, a city in China, in The virus can linger in small droplets and particles that can linger
December 2019. Early hypotheses suggested that the new virus in the air for minutes to hours. This method of transmission
may be linked to a seafood market in this city. But people with (air-borne transmission) can cause infection even if people are
no link to the market also became ill. Healthcare officials are still farther than 6 feet away from the infected person and even after
investigating its exact starting point (Johns Hopkins Medicine, that person has left the area (CDC, 2021e).
2021). Less commonly, a person may become infected by touching
The most common mode of transmission is air-borne droplets a surface or object that has the virus on it and then touching
expelled during face-to-face exposure during talking, coughing, the mouth, nose, or eyes. At this time, the risk of COVID-19
or sneezing. People who are within 6 feet of an infected person spreading from animals to people is considered low, but there is
or who have direct contact with that person are at greatest risk some limited evidence that the virus can spread from people to
of infection. Risk also increases when people are in cramped animals (CDC, 2021e).
quarters with infected persons (CDC, 2021e).
The usual time frame for symptom development after infection is lesions on hands and feet (Johns Hopkins Medicine, 2021;
5 days. However, this incubation period can vary, ranging from as Wiersinga et al., 2020).
early as 2 days after infection or as late as 14 days after infection The previous symptoms are common to many illnesses. However,
(Wiersinga et al., 2020). a significant symptom related to COVID-19 infection is the loss
Following are common signs and symptom (Johns Hopkins of taste or smell (Wiersinga et al., 2020).
Medicine, 2021; Wiersinga et al., 2020): Symptoms vary in intensity from asymptomatic to severe life-
● Fever. threatening illness. Symptoms can be mild at the start of illness
● Chills. but become most intense over a 5-to-7-day period (Johns
● Cough. Hopkins Medicine, 2021; Wiersinga et al., 2020).
● Fatigue.
● New loss of taste or smell. Severe disease may lead to the following complications (Sparks,
● Sore throat. 2021; Wiersinga et al., 2020):
● Body aches. ● Pneumonia.
● Runny or stuffy nose. ● Respiratory disease.
● Shortness of breath or difficulty breathing. ● Organ failure.
● Vomiting and diarrhea. ● Acute respiratory distress syndrome.
● Headache. ● Sepsis.
● Blood clots.
Less common symptoms are eye problems such as enlarged ● Acute kidney injury.
red blood vessels, swollen eyelids, excessive watering, and ● Additional viral and bacterial infections.
discharge; confusion; and skin changes such as painful, itchy
Diagnosis
Diagnosis is generally made using polymerase chain reaction
testing via nasal swab (Wiersinga et al., 2020).
Treatment
Treatment is generally supportive, focusing on addressing Patients who have not been identified and die at home are not
symptoms as they appear. Best practices for management of included in these data.
acute hypoxic respiratory failure and adult respiratory distress Preventive measures include wearing an appropriately fitted
syndrome (ARDS) should be followed. More than 75% of patients mask when outside the home, staying 6 feet away from persons
hospitalized with COVID-19 need supplemental oxygen therapy. not in your household, washing hands often with soap and water
Severe respiratory compromise may necessitate the need for for at least 20 seconds, or use of an alcohol-based hand sanitizer
invasive mechanical ventilation. It is important to note that that contains at least 60% alcohol. Masks should be washed
a disproportionate percentage of patients hospitalized with after each use and worn over the nose and mouth. Congested
COVID-19 and deaths from infection occur in lower income and gatherings, especially indoors, should be avoided. Avoid
minority populations. Hospital mortality from COVID-19 is about touching the face or shaking hands and touching others. Clean
15% to 20%, but is up to 40% in those patients who require and disinfect frequently touched surfaces on a daily basis (Tosh,
admission to the intensive care unit (ICU; Wiersinga et al., 2020). 2021).
Vaccines
As of this writing, two vaccines are in use in the US: BNT1162b2 apart, are given in the muscle of the upper arm. Side effects are
(Pfizer, Inc., and BioNTech) and mRNA-1273 (ModernaTX, Inc.; similar to those of the Pfizer vaccine.
CDC, 2021c). These vaccines are approved for adults 18 years A third vaccine, manufactured by Johnson & Johnson, has
of age and older. Studies are underway to determine safety and recently been approved. On February 26, 2021, vaccine advisers
use in children. With BNT1162b2, two injections, 21 days apart, to FDA recommended that the agency grant emergency use
are given in the upper arm muscle. Common side effects are authorization for the Johnson & Johnson vaccine, which would
pain, swelling and redness at the injection site, chills, tiredness, require only a single injection (Fox, 2021).
and headache. Side effects seem to be more common after
the second injection. With mRNA-1273, two injections, 28 days
High-risk groups
Groups at high risk for serious disease have been given priority ● Those with respiratory conditions: COVID-19 targets the
for obtaining COVID-19 vaccine. These groups include the lungs. People with serious respiratory disorders –such as
following (Mayo Clinic, 2021): chronic obstructive pulmonary disease (COPD), lung cancer,
● Older adults: The risk of developing serious symptoms moderate to severe asthma, cystic fibrosis, or pulmonary
increases with age. Those who are 85 and older are at the fibrosis – are at high risk.
highest risk.

● Those with chronic conditions: Those who have severe, ● Those with cancer and blood disorders: People who currently
chronic diseases – such as cardiac disease, diabetes, and have cancer and blood disorders such as sickle cell anemia
obesity – are also at high risk. are at increased risk for severe symptoms.
● Other conditions: Persons with weakened immune systems
and chronic renal or hepatic diseases are also at high risk.
Treatment
Treatment strategies are continuing to evolve. FDA and CDC FDA may also authorize the use of unapproved drugs or
websites offer the most current information. In addition to unapproved uses of approved drugs under certain conditions.
supportive measures, FDA (2021) provides the following For example, FDA has authorized emergency use of monoclonal
information about treatment. antibody treatments for the treatment of mild or moderate
FDA has approved the antiviral drug remdesivir (Veklury) for COVID-19 in adults and pediatric patients (ages 12 and older
adults and some pediatric patients with COVID-19 who are sick weighing at least 88 pounds) with positive results of direct SARS-
enough to need hospitalization. Veklury should be administered CoV-2 viral testing and who are at high risk for progressing to
only in a hospital setting or in a healthcare setting capable of severe COVID-19 or hospitalization (FDA, 2021).
providing acute care comparable to inpatient hospital care.
Conclusion
The National Center for Complementary and Integrative Health adults should consult with their healthcare providers as to the
has Thanks to long-term research, immunizations are now best way to determine their immunization status and what action
available for many diseases that were once significant causes to take if immunization is needed.
of serious complications and even death. Research continues in Members of healthcare professions must be aware that more
the area of immunization so that current vaccines may be made and more healthcare organizations are mandating that their
even more safe and effective, and that new vaccines may be employees receive influenza vaccine yearly. This trend may
developed to limit or prevent the occurrence of diseases for expand to include vaccination for other diseases as well, and
which there are currently no means of prevention. nurses must be prepared for such mandates. Military personnel
Some members of the public, including some healthcare and those in occupations that require international travel are at
professionals, have concerns about the number of vaccines greater risk of exposure to vaccine-preventable diseases.
administered, the timetable for administration, and the safety Nurses must also recognize how disease-causing pathogens
and effectiveness of immunization programs. Nurses should can be used as bioterrorist weapons. For example, the fact that
be aware of these concerns and be prepared to address them specimens of the smallpox virus are still maintained for research
when interacting with patients and families. Nurses should also purposes has triggered concerns that such specimens may be
be aware of their own concerns regarding vaccines and vaccine- used as weapons of terror in the US and other countries.
preventable diseases. These concerns should not interfere with Diseases that are considered eradicated, such as smallpox, or
objective patient education and counseling. under control have the potential to experience resurgence and
It is important that healthcare professionals be aware of potential cause dangerous epidemics if causative pathogens fall into the
vaccine side effects. Even though the vast majority of vaccines hands of those terrorists who would use them as weapons.
cause minimal, mild side effects, there remains the potential for Finally, all healthcare professionals must be aware of steps
serious adverse occurrences such as anaphylactic reactions in to take to prevent vaccine-preventable diseases in addition
a small percentage of the public. When assisting with vaccine to immunization. Basic infection control initiatives, especially
administration, nurses should meticulously help patients and frequent handwashing, can go a long way to prevent the
families identify potential risk factors for such reactions, including spread of disease. They must also be able, in the event that
allergies to vaccine components. these diseases are contracted, to teach family members and
Nurses and other healthcare professionals should also be other caregivers and close contacts how to avoid becoming ill
aware of the state laws that govern vaccine administration. For themselves.
example, what laws are in place regarding vaccination status Another aspect of prevention is to discourage the unnecessary
before children being enrolled in school? Are there exemptions use of antibiotics. Many people believe that taking antibiotics
to these laws? Laws vary across states in the US, so nurses must is a good way to prevent disease. They must be taught that
be aware of the laws governing immunizations in their particular prophylactic antibiotic therapy is useful only under specific
geographic location. Nurses must be able to help clarify these circumstances outlined by qualified healthcare providers. The
laws for patients and families and comprehend what type of overuse of antibiotics has contributed to the ever-growing
exemptions may apply-- medical, religious, or philosophical. problem of antibiotic-resistant pathogens. It is a matter of
Nurses must also be aware of the consequences of refusal to concern to all who work in healthcare. Researchers are constantly
receive vaccinations. For example, parents of unvaccinated looking for ways to develop new antibiotics to combat resistant
children may be held legally liable in some states if their children pathogens. But patient education about the dangers of
transmit a vaccine-preventable disease to another child. indiscriminate use of antibiotics is essential as part of the fight
Patients and families must also be aware of the effects of against drug-resistant pathogens.
acquiring vaccine-preventable diseases. Some diseases such as Vaccine-preventable diseases have decreased drastically thanks
rubella are mild and self-limiting; however, even these diseases to effective, vigorous immunization programs. Nevertheless,
can have serious consequences. Recall that a pregnant female there has been an increase in the number of cases of such
exposed to rubella may give birth to a baby with serious birth diseases caused, in large part, by people not receiving
defects as a consequence of such exposure. Additionally, all recommended immunizations. This increase can have drastic
diseases have the potential to cause complications, some of consequences, as in the case of recent deadly outbreaks of
which can be life altering. meningitis on college campuses, or as seen in current outbreaks
Adults often forget that they, too, need to receive vaccinations. of measles (the most contagious of childhood diseases) in
Vaccines to prevent influenza, pneumonia, and shingles are unvaccinated populations. Healthcare professionals must help
available. Older adults should be also informed of the risks patients and families understand the benefits of immunization
associated with COVID-19, pneumonia, and influenza. But that outweigh the potential side effects. With appropriate
many adults refuse such vaccines, which generally increases immunization programs, it is hoped that more and more vaccine-
the potential for severe outbreaks and life-threatening preventable diseases can be eradicated and individuals spared
complications. Adults are often unaware of the need for periodic the consequences of communicable diseases.
booster immunizations to ensure that they remain protected. All

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Centers for Disease Control and Prevention. (2019c). Meningococcal disease. https://www. Fox, M. (2021). FDA vaccine advisers recommend authorization of Johnson & Johnson’s
cdc.gov/meningococcal/surveillance/index.htmlCenters for Disease Control and Prevention. coronavirus vaccine.https://www.cnn.com/2021/02/26/health/johnson-coronavirus vaccine-
(2019d). Pertussis (whooping cough). https://www.cdc.gov/pertussis/clinical/disease- specifics. recommendation-vrbpac/index.html Gaston, S. C. & Yuengert, A. R. (2020). Mandate
html to vaccinate? Employers and required flu shots. https://www.employmentlawinsights.
Centers for Disease Control and Prevention. (2019e). Pertussis (whooping cough) surveillance com/2020/10/mandate-to-vaccinate-employers-and-required-flu-shots/ Goodson, J. (2014).
and reporting.https://www.cdc.gov/pertussis/surv-reporting.html Public health image. https://phil.cdc.gov/Details.aspx?pid=19434
Centers for Disease Control and Prevention. (2019f). Pneumococcal disease. Prevention. Harvard School of Public Health. (2017). Increase in pertussis outbreaks linked with vaccine
https://www.cdc.gov/pneumococcal/clinicians/index.html exemptions, waning immunity. https://www.hsph.harvard.edu/news/features/increase-in-
Centers for Disease Control and Prevention. (2019g). Rotavirus. About rotavirus. https://www. pertussis-outbreaks-linked-with-vaccine-exemptions-waning-immunity/ HHS.gov. (2020a).
cdc.gov/rotavirus/about/index.htmlCenters for Disease Control and Prevention. (2019h). Diphtheria. https://www.vaccines.gov/diseases/diphtheria
Rotavirus surveillance. https://www.cdc.gov/rotavirus/surveillance.html Centers for Disease HHS.gov. (2020b). Hib (Haemophilus influenzae type B). https://www.vaccines.gov/diseases/
Control and Prevention. (2019i). Routine measles, mumps, and rubella vaccination. https:// hib/index.html
www.cdc.gov/vaccines/vpd/mmr/hcp/recommendations.html HHS.gov. (2020c). Meningococcal. https://www.vaccines.gov/diseases/meningitis/
Centers for Disease Control and Prevention. (2019j). Tetanus. https://www.cdc.gov/tetanus/ HHS.gov. (2020d). Mumps. https://www.vaccines.gov/diseases/mumps/
about/index.html HHS.gov. (2020e). Rabies. https://www.vaccines.gov/diseases/rabies/index.html
Centers for Disease Control and Prevention. (2019k). Types of influenza viruses. https://www. History of Vaccines. (2018). History of polio. http://www.historyofvaccines.org/content/
cdc.gov/flu/about/viruses/types.htmCenters for Disease Control and Prevention. (2019l). timelines/polioImmunization Action Coalition. (2021). Vaccine timeline. http://www.immunize.
Vaccines and preventable diseases. Varicella vaccine recommendations. https://www.cdc.gov/ org/timeline/
vaccines/vpd/varicella/hcp/recommendations.html ImmunizeBC. (2020). If you choose not to vaccinate. https://immunizebc.ca/your-risks-and-
Centers for Disease Control and Prevention. (2019m). Vaccines for infants, children, and responsibilities-unvaccinated-child
adults: Pneumococcal vaccine recommendations.https://www.cdc.gov/vaccines/vpd/pneumo/ Johns Hopkins Medicine. (n.d.). Laparoscopic hysterectomy. https://www.hopkinsmedicine.
hcp/recommendations.html org/gynecology_obstetrics/specialty_areas/gynecological_services/treatments_services/
Centers for Disease Control and Prevention. (2019n). Vaccines for your children. Making the minimally_invasive_gy
decisionhttps://www.cdc.gov/vaccines/parents/why-vaccinate/vaccine-decision.html Johns Hopkins Medicine. (2020). Mandatory flu vaccination program. Johnshttps://www.
Centers for Disease Control and Prevention. (2020a). Administering HPV vaccine.https://www. hopkinsmedicine.org/mandatory_flu_vaccination/ Johns Hopkins Medicine. (2021). What is
cdc.gov/vaccines/vpd/hpv/hcp/administration.html coronavirus? https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus
Centers for Disease Control and Prevention. (2020b). Congenital rubella https://www.cdc.gov/ Kaiser, J. (2014). Six vials of smallpox discovered in U.S. lab. https://www.sciencemag.org/
vaccines/pubs/surv-manual/chpt15-crs.html news/2014/07/six-vials-smallpox-discovered-us-lab
Centers for Disease Control and Prevention. (2020c). Diphtheria. https://www.cdc.gov/ Kedlaya, D. (2019). Post-polio syndrome. http://emedicine.medscape.com/article/306920-
diphtheria/clinicians.html overview Kishner, S. (2019). Acute poliomyelitis. https://emedicine.medscape.com/
Centers for Disease Control and Prevention. (2020d). Diphtheria antitoxin (DAT). https://www. article/306440- overview#a5Life Magazine. Author. (1953). A better break for polio
cdc.gov/diphtheria/dat.html patients. Life Magazine, 127-128.
Centers for Disease Control and Prevention. (2020e). Disease burden of influenza. https:// Life Magazine. Author. (1954). The polio season. Life Magazine, 28.
www.cdc.gov/flu/about/burden/index.html?CDC_AA_refVal=https%3A%2F%2Fw ww.cdc.gov%2 Lippincott Williams & Wilkins (Author). (2017). Medical-surgical nursing made incredibly
Fflu%2Fabout%2Fdisease%2Fus_flu-related_deaths.htm easy (4th ed.). Lippincott Williams & Wilkins.
Centers for Disease Control and Prevention. (2020f). Haemophilus influenzae disease Marino, T. (2017). Viral infections and pregnancy. https://emedicine.medscape.com/
Including Hib. https://www.cdc.gov/hi-disease/clinicians.html article/235213-overview
Centers for Disease Control and Prevention. (2020g). Immunization. https://www.cdc.gov/ Mayo Clinic. (2019a). Cervical cancer. https://www.mayoclinic.org/diseases-conditions/
nchs/fastats/immunize.htm cervical-cancer/symptoms-causes/syc-20352501.Mayo Clinic. (2019b). Pneumococcal
Centers for Disease Control and Prevention. (2020h). Influenza. https://www.cdc.gov/nchs/ vaccination. https://www.cdc.gov/vaccines/vpd/pneumo/index.html.
fastats/flu.htm Centers for Disease Control and Prevention. (2020i). Influenza (flu): Health Mayo Clinic. (2019c). Rabies. https://www.mayoclinic.org/diseases-/rabies/symptoms-causes/
care workers need a flu vaccine.https://www.cdc.gov/flu/professionals/healthcareworkers.htm syc-20351821.
Centers for Disease Control and Prevention. (2020j). Measles (rubeola). Measles in 2020. Mayo Clinic. (2019d). Tetanus. https://www.mayoclinic.org/diseases- conditions/tetanus/
https://www.cdc.gov/measles/hcp/index.html Centers for Disease Control and Prevention. symptoms-causes/syc-20351625.
(2020k). Measles cases and outbreaks. https://www.cdc.gov/measles/cases-outbreaks.html Mayo Clinic. (2019e). Whooping cough. https://www.mayoclinic.org/diseases- conditions/
Centers for Disease Control and Prevention. (2020l). Meningococcal disease. https://www. whooping-cough/symptoms-causes/syc-20378973.
cdc.gov/meningococcal/about/risk- community.html Mayo Clinic. (2020a). Diphtheria. https://www.mayoclinic.org/diseases- conditions/diphtheria/
Centers for Disease Control and Prevention. (2020m). Meningococcal disease. symptoms-causes/syc-20351897. Mayo Clinic. (2020b). Infectious diseases A-Z: Pertussis cases
Meningococcal vaccination.https://www.cdc.gov/meningitis/bacterial.html increasing. https://newsnetwork.mayoclinic.org/discussion/infectious-diseases-pertussis-
Centers for Disease Control and Prevention. (2020n). Mumps cases and outbreaks. https:// cases-increasing/
www.cdc.gov/mumps/outbreaks.html Mayo Clinic. (2020c). Influenza (flu). https://www.mayoclinic.org/diseases- conditions/flu/
Centers for Disease Control and Prevention. (2020o). Pneumonia. https://www.cdc.gov/ symptoms-causes/syc-20351719. Mayo Clinic. (2020d). Mumps. http://www.mayoclinic.org/
nchs/fastats/pneumonia.htm diseases- conditions/mumps/basics/definition/con-20019914?p=1.
Centers for Disease Control and Prevention. (2020p). Rabies. https://www.cdc.gov/rabies/ Mayo Clinic. (2020e). Pneumonia. https://www.mayoclinic.org/diseases- conditions/
Centers for Disease Control and Prevention. (2020q). Recommended immunization pneumonia/symptoms-causes/syc-20354204.Mayo Clinic. (2020f). Polio. https://www.
schedule for children and adolescents aged 18 yearsor younger. https://www.cdc.gov/ mayoclinic.org/diseases- conditions/polio/symptoms-causes/syc-20376512
vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf Mayo Clinic. (2020g). Post-polio syndrome. https://www.mayoclinic.org/diseases-
Centers for Disease Control and Prevention. (2020r). Rubella. https://www.cdc.gov/ conditions/post-polio-syndrome/symptoms-causes/syc-20355669
vaccines/pubs/surv-manual/chpt14-rubella.html Mayo Clinic. (2020h). Shingles. https://www.mayoclinic.org/diseases- conditions/shingles/
Centers for Disease Control and Prevention. (2020s). Rubella in the U.S. https://www.cdc. diagnosis-treatment/drc-20353060Mayo Clinic. (2020i). Smallpox. https://www.mayoclinic.
gov/rubella/about/in-the-us.html org/diseases-conditions/smallpox/symptoms-causes/syc-20353027
Centers for Disease Control and Prevention. (2020t). Rubella vaccination. https://www.cdc. Mayo Clinic. (2021a). COVID-19: Who’s at higher risk of serious symptoms? https://www.
gov/rubella/vaccination.html mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-who-is-at-risk/
Centers for Disease Control and Prevention. (2020u). Shingles (herpes zoster). https://www. art-20483301
cdc.gov/shingles/hcp/clinical-overview.htmlCenters for Disease Control and Prevention. Mayo Clinic. (2021b). Varicella (Chickenpox). https://www.mayoclinic.org/diseases-
(2020v). Smallpox: Prevention and treatment. https://www.cdc.gov/smallpox/prevention- conditions/chickenpox/symptoms-causes/syc-20351282McKee, C. & Bohannon, K.
treatment/index.html (2016). Exploring the reasons behind parental refusal of vaccines. Journal of Pediatric
Centers for Disease Control and Prevention. (2020w). Vaccines & immunizations Pharmacology and Therapeutics, 21(2), 104-109.
Immunization schedules.https://www.cdc.gov/vaccines/schedules/index.html

MD Monthly Staff. (2019). 10 reasons to get vaccinated. https://mdmonthly.com/10- Whyte, C. (2019). Every country worldwide is not using the most effective polio vaccine.
reasons-to-get-vaccinated/ https://www.newscientist.com/article/2202331-every-country-worldwide-is- now-using-the-
Meadows-Oliver, M. (Clinical Ed.). (2019). Pediatric nursing made incredibly easy (3rd ed.). most-effective-polio-vaccine/
Wolters Kluwer. Wiersinga, W. J., Rhodes, A., & Cheng, A. C. (2020). Pathophysiology, transmission
Merck Manual Professional Version. (2020). Haemophilus infections. http://www. diagnosis, and treatment of coronavirus disease 2019.
merckmanuals.com/professional/infectious-diseases/gram-negative-bacilli/ JAMA, 324(8), 782-793.
haemophilus-infections Williamson, S. (2019). Pros and cons of required flu shots. http://www.ocsc.ca/pros-and-
National Cancer Institute. (2021). HPV and cancer. https://www.cancer.gov/about-cancer/ cons-of-required-flu-shots/Wikipedia, the Free Encyclopedia. (2021). Smallpox. https://
causes-prevention/risk/infectious-agents/hpv-fact-sheet en.wikipedia.org/wiki/Smallpox
National Conference of State Legislation. (2021). States with religious and philosophical World Health Organization. (2016). Frequently asked questions and answers on
exemptions from school immunizationrequirements. http://www.ncsl.org/research/ smallpox. http://www.who.int/csr/disease/smallpox/faq/en/World Health Organization.
health/school-immunization-exemption-state-laws.aspx (2018a). Europe observes a 4-fold increase in measles cases in 2017 compared to
National Health Service, (2018). Complications (mumps). https://www.nhs.uk/conditions/ previous year. http://www.euro.who.int/en/media-centre/sections/press-releases/2018/
mumps/complicationsNational Institute of Neurological Disorders and Stroke. (2020). europe-observes-a-4-fold-increase-in-measles-cases-in-2017- compared-to-previous-
Post-polio syndrome fact sheet 5. year
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Post- World Health OrganizationWHO. (2018b). Meningitis. https://www.who.int/health-topics/
Polio-Syndrome-Fact-Sheet#3172_5 meningitis#tab=tab_1
Nettleman, M. D. (2020). Hepatitis A and B vaccinations. https:/www.medicinenet.com/ World Health Organization. (2018c). Meningococcal meningitis. http://www.who.int/
hepatitis_immunizations/index.htm#what_is hepatitis mediacentre/factsheets/fs141/en/World Health Organization. (2019). Measles. https://
Pagana, K. D. & Pagana, T. J. (2018). Mosby’s manual of diagnostic and laboratory tests (6th www.who.int/news-room/fact-sheets/detail/measles
ed.). Elsevier.Ratini, M. (2020). Flu treatment. https://www.webmd.com/cold-and-flu/flu- World Health Organization. (2020a). Does polio still exist? Is it curable? http://www.
treatment#1 who.int/features/qa/07/en/World Health Organization. (2020b). Guidance on anthrax:
Rice, B. (n.d.), Smallpox. https://www.cdc.gov/smallpox/images/clinician/clinical-disease- Frequently asked questions. http://www.who.int/csr/disease/Anthrax/anthraxfaq/en/
patient.jpg Rosenfeld, A. (1967). Breakthrough by Du Pont: A drug that blocks viruses. World Health Organization. (2020c). Hepatitis A. http://www.who.int/mediacentre/
Life Magazine, 60A-61A.Samji, N. S. (2017). Viral hepatitis. https://emedicine.medscape.com/ factsheets/fs328/en/World Health Organization. (2020d). Hepatitis B. http://www.who.
article/775507-overview Sparks, D. (2021). Mayo Clinic Q & A podcast: COVID-19 variants and int/mediacentre/factsheets/fs204/en/World Health Organization. (2020e). Immunization,
the evolving science. vaccines, and biologicals: influenzae type b (Hib).https://www.who.int/immunization/
https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-qa-podcast-covid-19- diseases/hib/en/
variants-and-the-evolving-science/Tosh, P. K. (2021). Coronavirus: What is it and how can World Health Organization. (2020f). Rabies. http://www.who.int/mediacentre/factsheets/
I protect myself? https://www.mayoclinic.org/diseases- conditions/coronavirus/expert- fs099/en/
answers/novel-coronavirus/faq-20478727 World Innovation Summit for Health (WISH). (2019). 4 reasons why parents are refusing
S. Department of Defense. (2002). Bush orders smallpox hots for military, first responders. to vaccinate their children, and 4 reasons why they (really) shouldn’t. https://www.wish.org.
http://archive.defense.gov/news/newsarticle.aspx?id=42388 qa/blog/4-reasons-why-parents-are-refusing-to-vaccinate-their-children-and-4-reasons-
WebMD. (2020). Flu treatment https://www.webmd.com/cold-and-flu/flu-treatment why-they-really-shouldnt/
Youngdahl, K. (2014). College meningitis B outbreaks and a new vaccine. https://www.
historyofvaccines.org/content/blog/college-meningitis-b-outbreaks-and-new-vaccine
STAYING HEALTHY: VACCINE PREVENTABLE DISEASES

1. The correct answer is C. 7. The correct answer is A.
Rationale: People who have minor illnesses such as a cold may Rationale: HBV can be transmitted via sexual contact through
be vaccinated. People who are moderately or severely ill should blood, semen, saliva, or vaginal secretions. HBV is considered to
wait until they recover before getting MMR vaccine. be a sexually transmitted disease.
2. The correct answer is D. 8. The correct answer is D.
Rationale: Children should be vaccinated with a total of four Rationale: The nurse is eliciting Brudzinski’s sign. The patient is
doss of IPV, one dose at each at ages 2 months, 4 months, 6 placed in the dorsal recumbent position and the head is flexed
through 18 months, and 4 through 6 years. upward. Meningeal irritation is indicated if neck flexion causes
flexion of hips, knees, and ankles. If the patient also flexes
their hips and knees, there may be meningeal irritation and
Rationale: Asymptomatic carriers should be placed in respiratory
inflammation, which are indicators of meningitis.
or contact isolation (for cutaneous findings) until at least two
subsequent cultures, taken 24 hours apart after therapy has 9. The correct answer is C.
stopped, are negative. Rationale: If the patient has a history of a serious precancer, she
should continue to have testing for at least 25 years after that
condition was found, even if the testing goes past age 65.
Rationale: The measles virus remains active and contagious
in the air or on infected surfaces for up to 2 hours. It can be 10. The correct answer is A.
transmitted by an infected person from 4 days before the onset Rationale: People who should not receive the Hib vaccine
of the rash to 4 days after the rash erupts. It is very likely that include infants younger than 6 weeks, those who have had a life-
susceptible persons with close contact to a measles patient will threatening reaction to the vaccine in the past, and people who
develop the disease. Measles virus can remain infectious in the have a serious allergy to any of the vaccine’s ingredients (HHS.
air for up to 2 hours after an infected person leaves an area. gov., 2020b).
5. The correct answer is A. 11. The correct answer is D.
Rationale: The incubation period for varicella is 10 to 21 days. Rationale: Category II contact occurs when there is nibbling of
The disease is communicable beginning up to 5 days before the the skin, minor scratches, or abrasions without bleeding. PEP is
body rash appears and continues until all of the lesions on the necessary. If someone has never had a rabies vaccine, the first
skin are crusted over. dose is administered as soon as possible.
6. The correct answer is B. 12. The correct answer is A.
Rationale: Shingrix was 97% effective in preventing shingles in Rationale: Inhalation anthrax is the most serious form of the
adults 50 to 69 years of age. disease. It is also the rarest form.
Course Code: ANCCNC10SH22

Test Expires: 5/13/2023
1. ANCCNC03DS22 2. ANCCNC03CH 3. ANCCNC04FT22 4. ANCCNC02PS 5. ANCCNC05MP22 6. ANCCNC3MF22 7. ANCCNC10SH22

NURSING - COURSE EVALUATION (ANCCNC3022C - Required)
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3. The course was relevant to my practice. 9. What I have learned from this course will have an impact on my knowledge.
4. I would recommend this course to my peers. 10. What I have learned from this course will have an impact on patient outcome.
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6. The course was well-organized and clear.
An Overview of Dietary Supplements for Nurses Cultural Humility for Healthcare Professionals
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Managing Difficult Patients for Healthcare Professionals Mindfulness for Healthcare Professionals Staying Healthy: Vaccine Preventable Diseases
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Cultural Humility for Healthcare Professionals 15

Health Care Management of Patients with Substance Use Disorders 51

Mindfulness for Healthcare Professionals 87

Staying Healthy: Vaccine Preventable Diseases 102

Course Participant Sheet 146

How much will it cost?

Best Value - Save $164.70 - All 30 Hours 30 $32.95

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Page 1 Book Code: ANCCNC3022C EliteLearning.com/Nursing

Page 3 Book Code: ANCCNC3022C EliteLearning.com/Nursing

CATEGORIES OF DIETARY SUPPLEMENTS

Page 5 Book Code: ANCCNC3022C EliteLearning.com/Nursing

Page 7 Book Code: ANCCNC3022C EliteLearning.com/Nursing

Page 9 Book Code: ANCCNC3022C EliteLearning.com/Nursing

Course Code: ANCCNC03DS22

Race, ethnicity, and immigration

Self-Assessment Quiz Question #9

Case study: Linda Rogers

1. The correct answer is B. 7. The correct answer is B.

Course Code: ANCCNC03CH

FUNDAMENTALS OF TELEHEALTH: REGISTERED NURSING PRACTICE IN THE VIRTUAL CARE

BENEFITS AND BARRIERS TO USING TELEHEALTH

Knowing the patient

FUNDAMENTALS OF TELEHEALTH: REGISTERED NURSING PRACTICE

Course Code: ANCCNC04FT22

SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

Table 1. Factors Associated with the Development of Alcohol-Related Disorders

Screening for alcohol use disorder

Self-Assessment Quiz Question #10

HEALTH CARE MANAGEMENT OF PATIENTS WITH SUBSTANCE USE DISORDERS

Course Code: ANCCNC02PS

FACTORS THAT MAY INCREASE THE RISK OF WORKPLACE VIOLENCE

Book Code: ANCCNC3022C

INCIDENCE OF WORKPLACE VIOLENCE IN HEALTHCARE SETTINGS

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

THE HEALTHCARE PROFESSIONAL-PATIENT CYCLE OF MANIPULATION

Book Code: ANCCNC3022C

Book Code: ANCCNC3022C

MANAGING DIFFICULT PATIENTS FOR HEALTHCARE PROFESSIONALS

Course Code: ANCCNC05MP22

Book Code: ANCCNC3022C

INFORMAL APPROACHES TO MINDFULNESS

FORMAL (STRUCTURED) APPROACHES TO MINDFULNESS

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