Notable Nursing - Cleveland Clinic

Feature Story
New Nursing Institute
Model Unites Nurses,
Benefits Patients - p. 01
Also Inside
Teaching Patients to Live and Cope with
Chronic Pain - p. 04
Handling the Impaired Professional - p. 06
Expert Nursing Care by Phone - p. 08
Notable Nursing
A Publication For Nurses By Nurses | Fall 2008

Notable Nursing clevelandclinic.org/notable
From the
Editor
Table of Contents
p.01 Cover Story: New Nursing
Institute Model
p.04 Teaching Patients to Manage
Chronic Pain
p.06 Handling the Impaired
Professional
p.08 Expert Nursing Care by Phone
p. 10 orthopaedics Conference
Coverage
p. 13 Dimensions in Cardiac Care
Coverage
p. 16 Nursing Research Conference
Coverage
p. 18 ET/woC Nursing Conference
Coverage
866.219.7149 Fall 2008
Welcome to the fall 2008 edition of Notable Nursing, a pub-
p. 21 urology/gynecology Nursing
lication for nurses by nurses, now in its 8th year of printing.
Conference Coverage
In this issue you will read of the newest transition for us as
p. 24 Evaluating Nurses’ knowledge
nurses at Cleveland Clinic — we are now the Nursing Institute
of Diabetes Skills
at Cleveland Clinic. This change in nomenclature speaks of our
enhanced status as nurses, our collaboration with all providers
across a patient’s continuum of care, and our unity as nurses
across all care settings. Our redesignation as a Magnet-status
facility this past spring and the new institute status have invigorated
our nursing practice and you will see evidence of this in
the articles we have included.
p. 25 Nurse of Note
Executive Editor
Michelle Dumpe, PhD, MS, RN
Email comments about Notable
Nursing to dumpem@ccf.org
The structure of the Nursing Institute consists of a Chief
Nursing Officer who oversees two Associate Chief Nursing
Officers. There are also Nursing Directors designated in each
clinical institute who oversee nursing staff for that institute.
According to Debra Albert, MSN, MBA, RN, NEA-BC, Interim
Chief Nursing Officer, “The new Nursing Institute brings
2
You’ll also see that we’ve had a change in leadership of the
Nursing Institute in the past few months. Debra Albert, MSN,
MBA, RN, NEA-BC, is currently serving as Interim Chief Nursing
Officer. She took the helm of the institute in June. A national
search is under way to fill the role permanently.
The renewed emphasis by the Centers for Medicare and Medicaid
Services (CMS) on hospital-acquired infections, pressure
ulcers and patient falls, as well as the associated potential loss of
revenue, provide opportunities for our nurses to excel again. Our
evidence-based nursing practice is defined by three domains of
Editorial Board
Debra Albert, MSN, MBA, RN, NEA-BC
INTERIM CHIEF NuRSINg oFFICER
Mary Beth Modic, MSN, RN, CNS
DIABETES AND PATIENT EDuCATIoN
Claudia Straub, MSN, RN, BC
NuRSINg EDuCATIoN
Robbi Cwynar, BSN, RNC
THoRACIC & CARDIovASCuLAR SuRgERy
Nancy Albert, PhD, RN, CCNS
NuRSINg RESEARCH
Christina Canfield, MSN, RN, CNS
like-minded individuals together. It gives nurses an opportunity
to come together and build on each other’s strengths,
regardless of the practice setting. It enables us to learn from
each other and truly provide a seamless continuum of care
for the patient.”
Recognizing the Important Contribution of Nurses
Albert says the new approach demonstrates Cleveland Clinic’s
commitment to the central role nurses play in patient care. “It
demonstrates recognition of our important contribution to
patient care within a physician-led organization,” she says.
1
practice — comfort, safety and education — and positions us to
impact these patient care outcomes. It also reinforces our ability
MEDICINE
Deborah Solomon, MSN, RN, CNS
SuRgERy
Under the new model, inpatient and outpatient nurses are
more closely aligned, which benefits patients by helping to
to impact the financial viability of Cleveland Clinic.
Barbara Reece, MSN, RN
reduce the likelihood of errors. Inpatient and outpatient
Notable Nursing reflects the commitment that Cleveland Clinic
nurses share to deliver the highest quality patient care, a
commitment that is responsible for Cleveland Clinic’s ongoing
ranking as one of the nation’s top-rated hospitals. Please share
it with your colleagues. You can review past editions of Notable
Nursing by visiting clevelandclinic.org/notable and clicking on
DIRECToR, MEDICINE AND BEHAvIoRAL HEALTH
Christine Harrell
MANAgINg EDIToR
Amy Buskey-Wood
ART DIRECToR
Lori J. Schmitt
MARkETINg
Photography
nurses collaborate in a process that incorporates all healthcare
professionals, including physicians, social workers and
case managers, as well as the patient and family. It calls for
everyone to be involved with and in agreement on the patient’s
care. “Nurses have more of a voice in setting strategy for
patient care,” Albert remarks.
Notable Nursing Newsletter.
CovER PHoTo: BARNEy TAxEL
PHoTogRAPHERS: ToM MERCE, DoN gERDA,
Sincerely,
wILLIE MCCALLISTER, STEvE TRAvARCA, yu
Michelle Dumpe, PhD, MS, RN
kwAN LEE, NEIL LANTzy, AL FuCHS, RuSSELL
LEE, ANDREw MooRE
Executive Editor
To add yourself or someone else to the mailing list,
change your address or subscribe to the electronic form
of this newsletter, visit clevelandclinic.org/notable.
cover story
New Nursing Institute Model
Unites Nurses, Benefits Patients
Last year, Cleveland Clinic changed its organizational structure
to institutes — a new model of healthcare that organizes clinical
areas around organ and disease systems rather than individual
specialties. The consolidation of disciplines and collaboration
on research allows us to better serve our patients. The former
Division of Nursing also was reorganized into an institute, uniting
nurses across all care settings and clinical institutes.

Notable Nursing clevelandclinic.org/notable
New Institute in Action
The Neurological Institute was one of the first institutes to
be established under the new model. Kim Hunter, MSN,
RN, MBA, Nursing Director for the Neurological Institute
says, “Even though we were caring for the same patients
(under the former Division of Nursing model), we were in our
separate divisions under the traditional format and didn’t
communicate well. It was a more fragmented approach to
patient care.”
In addition to benefits for patients, she points to advantages
for the staff. “From a nursing perspective, we now work
together as a team. Many different nurses are participating
and communicating daily about the patients’ care,” Hunter
says. She explains that, within the Neurological Institute,
they have quarterly town hall meetings during which nurses
update each other on issues, talk about what’s going on in
general, and share how they measure patient care outcomes.
The Physician Chairman of the institute also shares new
information with the nursing staff.
866.219.7149 Fall 2008
“Improved communications flow has
made a big difference.”
– Kelly Hancock, MSN, RN, CNA-BC
Getting to Know You
Hunter notes that, when the new institute model was being
implemented and people were coming together more, she
often heard remarks such as “I really didn’t know you before.”
And “I really had no idea what you did in your area.” “With
improved communication, we know each other much better
now,” she says.
Kelly Hancock, MSN, RN, CNA-BC, Nursing Director for the
Heart & Vascular Institute, agrees with Hunter about the
positive new model. “It’s going very well for us,” she says.
2
quote
“Improved communications flow has made a big difference.”
Hancock is a member of the Heart & Vascular Institute
3
Executive Council, which includes the institute’s chairmen of
“From a nursing perspective, we now
cardiothoracic surgery, cardiology, and vascular surgery, as
work together as a team.”
well as the institute’s co-administrators. “Our Heart & Vascular
Institute Advisory Council, which includes myself and the
– Kim Hunter, MSN, RN, MBA
“On a smaller scale,” she says, “I meet weekly with the nurse
co-administrators, meets bi-weekly,” Hancock explains. “We
discuss what was covered at the Executive Council and filter
the pertinent information to front-line staff.” Conversely,
front-line staff provides input for them to share with the
Executive Council.
managers, assistant nurse managers, clinical instructors, and
A Win-Win Concept
clinical nurse specialists on both the inpatient and ambulatory
There’s another plus to the many patient benefits and staff
side. Although many of these providers do not report directly
advantages of the new nursing institute model — the ability
to me, it is really helpful to get together regularly to discuss
to attract and retain nurses. Nurses desire to be part of the
projects, issues, new information and do problem solving.”
decision-making process, and this approach gives them a seat
at the table, impacting patient outcomes and setting patient
care strategy.
quote
The new institute model provides “a great vehicle for nurses
to help guide and lead patient care; this is Magnet nursing,”
Albert says.
Email comments to albertd@ccf.org; hunterk@ccf.org; or hancock@ccf.org.

Pain Management Programs
Teach Adults and Children
How to Live and Cope with
Chronic Pain
Few conditions are as debilitating or as difficult to treat as chronic pain. Cleveland Clinic’s pediatric
and adult pain management programs have met with success in this challenging specialty by applying
a team approach that incorporates nurses, physicians and therapists. The programs share a
national reputation for helping patients overcome their pain and return to as normal a life as possible.
Janet zaibek,
MSN, RN, CPNP
Silvia garcia,
MSN, RN
Pain Management Program for Children
The Pediatric Pain Rehabilitation
Program at Cleveland Clinic Children’s
Hospital, Shaker Campus, is designed
to meet the unique needs of children
with chronic pain. The most common
diagnosis is complex regional pain
syndrome or reflex sympathetic
dystrophy and headache.
“These are complex patients who have
exhausted all other possibilities and
usually have been in the healthcare system
for awhile,” says Janet Zaibek, MSN,
RN, CPNP, inpatient nurse manager.
“We offer a structured behavior modification
approach to help them cope with
their pain.”
Program initiators David Rothner, MD,
a pediatric neurologist, and Michael
Stanton-Hicks, MD, a pain management
specialist, are internationally respected
pioneers in pediatric pain management.
Unique in the United States,
the program includes two weeks of
inpatient care and one week of outpatient
follow-up.
Treatment begins on Monday morning
with therapy sessions. For some
patients, this is the first significant
physical activity they have been required
to perform for months, Zaibek says.
“Chronic pain has strong psychological
and enabling elements, and our
program deals with all aspects of pain,”
she notes. “In collaboration with the
other team members, the primary nurse
works one-on-one with each child on
established goals, coordinates and
recommends services and monitors the
child’s behavior and progress.”
Patients follow a rigorous daily therapy
schedule with Sundays free to visit their
families. Nurses help set goals for these
days that will re-integrate the child into
normal community, school and family
life, Zaibek explains.
After discharge from the inpatient area,
patients return daily for another week of
outpatient therapy and behavior modification.
“By this phase of treatment,
their pain levels usually decrease, they
are walking, interacting socially, have
reduced their medication level and are
ready to return to school,” Zaibek says.
“The measure of success is the nurse’s
evaluation of each child’s accomplishments.”
Adult Chronic Pain Management
The Adult Chronic Pain Rehabilitation
Program is under the direction of
internationally known pain specialist
Edward Covington, MD. Established
in 1979, the program attracts patients
from around the United States, with a
maximum of 18 patients enrolled at a
time.
Prior to admission, each patient undergoes
a comprehensive evaluation completed
by an advanced practice nurse
to determine if he or she meets criteria
for admission. “We frequently receive
referrals of patients who are desperately
searching for a cure for their pain,” says
Silvia Garcia, MSN, RN, Director, Patient
Care Operations. “The primary goal of
the program is to teach the individual
how to effectively cope and function
despite the presence of chronic pain.”
During the intensive three-week
program, a specially trained nurse acts
as case manager for each patient. The
Chronic Pain Rehabilitation nursing
staff includes seven RNs and four APNs.
“The nurse case managers play an
integral role in coordinating services
with the multidisciplinary team and
the patient’s families,” Garcia says.
Intricate medication management and
consistent guidance/support within a
behavior modification model are the
primary functions of the case managers.
“All of our nurses have 15 to 20 years of
experience in psychiatry, in addition to
other areas of clinical expertise,” Garcia
says. “They are truly committed to a patient’s
holistic recovery and well-being.”
Following discharge, patients and their
families return for monthly aftercare
groups. The sessions are facilitated by
nurses, therapists and other healthcare
professionals. Aftercare is designed to
help patients transition from a structured
environment to their life at home,
work and community.
Email comments to zaibekj@ccf.org; or garcias@ccf.org.
Fixed-Wing Aircraft Added to
Critical Care Transport Fleet
Cleveland Clinic is able to go to new lengths to transport highly
complex patients, including those who are critically ill, with the addition
of two medical transport jets. The aircraft went into service
on July 1 and are able to reach Cleveland Clinic patients in need
wherever they are, even overseas. Critical Care Transport Team
constellation is customized based on the needs of the individual
patient and can serve infants, children and adults. Sophisticated
communications allows for in-flight interaction with the referring
doctor as well as any specialty at Cleveland Clinic. These dedicated
jets join our fleet of critical care transportation vehicles, which includes
mobile intensive care units and helicopters.
For more information, visit our website at
clevelandclinic.org/criticalcaretransport
Christopher Manacci, MSN, RN, ACNP, Cleveland
Clinic Emergency Department and Critical Care, is
part of the Critical Care Transport team.

Notable Nursing clevelandclinic.org/notable
It is estimated that as many as 8 to 12 percent of healthcare professionals
will develop a substance-related disorder at some point in their
career. Their knowledge of medications, access to substances, job
stress, tendency to self-treat, and their continuous focus on the needs
of others puts them at increased risk for substance abuse.
Recognizing the importance of addressing this issue of
patient safety and employee health, Cleveland Clinic
established a new program — the Licensed Professionals
Health Program (LPHP) — in early 2008 expressly to help
licensed professionals with substance-abuse problems.
“We customized our program by creating a hybrid of support
advocacy case management programs out there,” explains
Nichole Capitanio, LISW, director of the new program. The
program offers sensitive, comprehensive and confidential
assistance. “We provide impaired professionals support at
every step of their treatment, rehabilitation and re-entry,” she
notes. “They receive structured case management services,
advocacy and support in their recovery process. We coordinate
with their treatment providers, managers and Human
Resources to facilitate their re-entry process. Once they’ve
returned to work, they’re followed in a monitoring program
that includes compliance with after-care recommendations,
work functioning and licensure status.”
Information is handled on a need-to-know basis only,
and strict confidentiality procedures are followed, with
the exception of threats to patient safety and reporting
requirements mandated by law.
Capitanio says that voluntary self-referral is encouraged,
although employees may be referred to the program by
Human Resources, the CONCERN Employee Assistance
Program, the individual’s supervisor or other professionals
worried about the individual’s ability to function. There is
no cost for LPHP services. Cleveland Clinic provides health
insurance benefits, medical leave and salary continuation for
professionals getting treatment.
Email comments to capitan@ccf.org.
866.219.7149 Fall 2008
What to do
If you suspect a colleague is impaired
Document specific examples or patterns
of concerning behavior; if there are
unmistakable signs of impairment, bring
them to your supervisor’s attention
immediately.
Privately discuss your observations with
your manager (focus on your observations
without being judgmental).
Handling the Impaired Professional
Don’t turn a blind eye! It is not your
responsibility to diagnose the problem,
only to ensure that a problem is recognized
before a patient is harmed. Early recognition
is the key to ensuring a health professional
receives the help they need to remain
healthy and practice safely.
6
Don’t cover for your colleague. It only
hinders them from receiving help.
7
If you believe you may be impaired
Seek out confidential assistance from your
organization.
Talk to a trusted friend or colleague.
If you are suspected of being impaired
Remain calm.
Listen carefully to the concerns being
presented to you.
know people have observed changes in your
behavior and practice and are concerned.
Ask yourself, may this be true? what’s been
going on in my life recently?
know that you will be asked to complete
a chemical dependency or mental health
assessment
Remember – your colleagues are trying to
help you by ensuring your health and safety
to practice.

Notable Nursing clevelandclinic.org/notable
Providing Expert Care
Through the Telephone
Cleveland Clinic Nurses Give Advice,
Calm Anxiety on Phone Lines
“My baby keeps pulling at his ear and I think he has a
temperature. What’s wrong?” “My husband’s doctor is talking
about some kind of seeds for his prostate cancer. What is
that?” “Why are my periods so irregular?”
Answering questions like these are all in a day’s work for
the Cleveland Clinic nurses who staff phone lines. They
are experts at applying their communication skills and
their nursing expertise to connect patients with doctors,
departments or more information.
The Cleveland Clinic Cancer Answer Line, established in
866.219.7149 Fall 2008
1992, was one of the first such resources in the country. Ruth related, 30 percent are physician referral requests, and 20
8
Fritskey, MSN, RN, who has been answering the line for 15 percent are for health information. “We are the continuity
9
years, and Josette Snyder, MSN, RN, help some 350 people a of care, the link between the doctor’s office and the patient.”
month by phone.
Kruger says.
“A huge part of what we do is education,” Fritskey says.
“People hear that word cancer from their doctor and they go
into shock. Then when they get home they realize they had
many other questions that they wish they had asked. That’s
when they call us.”
Fritskey and Snyder rely on their years of experience in oncology
nursing and their education to answer questions, help the
people on the other end of the phone, and determine what
type of specialist each person should see.
And they do it all in about 10 minutes — the duration of a typical
call. “It’s a matter of knowing what questions to ask and
getting a discussion going with the patient,” Fritskey explains.
The same principle applies for the nurses who answer the
Cleveland Clinic Nurse on Call line 24 hours a day every day of
the week.
“We are here for anyone who wants to call with a question, a
symptom or a problem,” says Nurse Manager Robin Kruger,
RNC, BSN. “We take the time to find out what’s wrong, where
they need to go and how to get them there.” (See Nurse of
Note, page 25, for more on Robin Kruger and Nurse on Call.)
The nurses, in teams of four to eight on a shift, apply their
critical thinking and listening skills to get to the patient’s
“bottom line” problem, she explains, by following a series of
computerized guidelines to identify the problem. From there,
they either provide guidance for an immediate need or refer
the patient to the appropriate Cleveland Clinic department
for an appointment.
About half of the 10,000 to 12,000 calls a month are symptom-
Mary McDonnell, RN, fills a similar role with the 4HER line
in the Obstetrics and Gynecology Institute and Center for
Specialized Women’s Health. As a patient nurse advocate, she
specializes in answering calls about women’s health, talking
to about 40 people a day.
“My job is to examine the information the caller is providing
to identify her specific problem and risks and find the safest
way to help her,” McDonnell explains. “When a woman calls
with a symptom, I help determine what the main problem is
and who she should see first.”
McDonnell draws on her more than 20 years as a Cleveland
Clinic nurse to know what questions to ask. Her solid
working relationship with many Cleveland Clinic physicians
helps her connect patients with the right specialist in the
Women’s Health Center or elsewhere in Cleveland Clinic.
These nurses share a passion for this special brand of
nursing and its unique rewards. “You can hear in the person’s
voice when the light bulb goes on,” Fritskey says. “It’s very
rewarding when you know that you have helped the person on
the other end of the phone through their anxiety.”
Email comments to krugerr@ccf.org; mcdonnm@ccf.org; or fritskr@ccf.org.
Robin kruger, RNC, BSN
“We are here
for anyone who
wants to call
with a question,
a symptom or a
problem.”
“When a woman
calls with a
symptom, I help
determine what
the main problem
is and who she
should see first.”
Mary McDonnell, RN
Ruth Fritskey, MSN, RN
“A huge part of
what we do is
education.”

8TH ANNUAL ORTHOPAEDICS CONfERENCE ExCELLENCE THROUgH EDUCATION
Notable Nursing clevelandclinic.org/notable
The orthopaedics conference, held feb. 1 at Cleveland Clinic, was directed by Deborah L.
DeMars, RN, RNfA, ONC, Ambulatory Clinical Manager in the Department of Orthopaedic
Surgery, and Dawn gerz, RN, RNfA, ONC, Clinical Coordinator and Nurse Clinician in the
Section of Hand and Upper Extremity of the Department of Orthopaedic Surgery.
Diane L. Tusek, RN, BSN, was the guest faculty of the conference. Diane is the president
and founder of guided Imagery, Inc., and a leading researcher of the mind-body connection.
She is the former Director of Research and Director of the guided Imagery Program at
Cleveland Clinic.
Maintaining Resiliency in
Today’s Hectic World
Diane L. Tusek, RN,BSN | guided Imagery
guided imagery is a simple, low-cost tool that has been clinically shown to
significantly decrease stress, anxiety and pain and enhance coping skills.
866.219.7149 Fall 2008
Results of Total Arthroplasty
Brian g. Donley, MD* | James Sferra, MD | Cleveland Clinic
Historically, the only option for a patient with painful ankle
arthritis was arthrodesis. Although ankle motion was lost,
arthrodesis successfully relieved pain, but the biomechani-
measurement methods make it difficult to determine an
overall success rate for the second-and third-generation TAA
implants, but reported results in large numbers of patients
cal alterations from ankle arthrodesis often resulted in the
10 development or exacerbation of arthritis in other joints, as
11
The power of the mind is used to help the body heal, maintain
health, or relax by way of an inner communication and also
to form an emotional connection between the mind, body
Guided imagery, by way of a guided imagery CD, encourages
the listener to focus on the present moment and promote
his or her inner strength, courage and resilience. It has
well as complications such as nonunion, malalignment,
infection, and decreased gait speed and mobility.
and spirit. It involves all the senses of touch, smell, sight and a dramatic impact on slowing down a racing, busy mind
The success of total hip and knee replacement gave hope
sound.
and keeping thoughts in focus. It is an additional tool that
that equally good results could be obtained with total ankle
This technique is now routinely used with patients in
healthcare settings to ease their stress and promote a sense
of peace and tranquility at a difficult time. With guided
imagery, patients are empowered, motivated and enthusiastic
participants in their care. This has a marked impact on
patient satisfaction because it facilitates a patient’s sense of
healthcare professionals can use to enhance the overall
quality of patient care.
Staff and family members can use it for their own stress
management as well. In addition to decreasing stress, anxiety
and pain and enhancing coping skills, guided imagery has
been clinically shown to decrease insomnia, blood pressure
arthroplasty (TAA). Beginning in the 1970s, multiple designs
of ankle prostheses were created and many appeared to
provide good short-term results. Patient satisfaction with
these first-generation implants ranged from 19 percent to 81
percent, with results deteriorating with longer follow-up, and
long-term studies indicated that ankle arthroplasty was not
recommended for rheumatoid arthritis.
accomplishment, comfort and hope.
and angina, and to strengthen the immune system. It can
help with pre-and post-medical and surgical treatments and
offers other benefits as well. Guided imagery can help provide
coping strategies that will last a lifetime.
Second-generation ankle prostheses were of two basic
designs: three-component mobile-bearing and twocomponent
fixed-bearing with varying degree of constraint
(constrained, semiconstrained, unconstrained).
Fixed-bearing designs are less likely to break or dislocate,
but mobile-bearing designs provide greater congruence and
theoretically less wear. The Salto Talaris ® are dramatically superior to those reported with earlier
designs.
Third-generation designs are now being used worldwide.
These designs vary in the area covered, contours of the
articulating surfaces, materials, and fixation techniques, but
all have been reported to provide exceptionally good results.
In addition to improved prosthesis design and fixation
methods, other factors that likely have contributed to
improved results are improved patient selection, refined
indications, meticulous handling of soft tissues, less
dissection requirements for low-profile implants, and better
postoperative protocols.
Because TAA is a complex procedure and each implant
design presents unique challenges, there is a distinct
learning curve, and surgeon experience with TAA has been
shown to improve outcomes and survival rates.
prosthesis has
combined these two design features by placing the mobile
bearing concept into the instrumentation.
Differences in patient selection, prosthesis used, length
As implant designs continue to improve and experience with
the procedure increases, the outcomes of TAA are beginning
to reach those of total hip and knee arthroplasty. The
challenge is to develop a prosthesis that more closely mimics
the natural anatomy of the ankle joint and reliably provides
long-term pain-relief and improved function.
of follow-up, end-point for survival determinations (re-
* Dr. Donley is a paid consultant for Tornier, manufacturer of the
operation or failure leading to arthrodesis), and outcomes Salto Talaris ® prosthesis.
8TH ANNUAL ORTHOPAEDICS CONfERENCE ExCELLENCE THROUgH EDUCATION

8TH ANNUAL ORTHOPAEDICS CONfERENCE ExCELLENCE THROUgH EDUCATION
Pos†-Operative Care of the
Ankle fusion Patient
Donna Morgan, RN, RNfA | Cleveland Clinic
The goal in caring for the post-operative ankle-fusion patient
is to control the significant post-op pain the first 3-5 days
while decreasing the need for oral pain medication. Sending
the patient home with a popliteal nerve block with infusion
pump is an effective option.
Elevation is a critical component to reduce swelling and
promote wound healing. The ankle must be positioned above
heart level and heel suspended off of pillow.
Birmingham Hip Resurfacing
Peter Brooks, MD, fRCS (C) | Cleveland Clinic
Birmingham hip resurfacing, developed in the United Kingdom,
received fDA approval in 2006 as an alternative to hip replacement
in younger patients.
Hip resurfacing is very different from hip replacement. Instead
of replacing the femoral head and inserting a stem, a
metal shell covers the damaged surface.
The advantages of hip resurfacing are many:
• Keeps the femoral head and neck
• Normal biomechanics loads the femur
• No stress shielding or distal loading
• Less pain from surgery
• Better proprioception, more normal “feel”
• Potential for greater range of motion and improved
bone density
There is also less chance of leg length inequality, and failure
is easily converted to total hip replacement. There are some
disadvantages, however, including femoral neck fracture,
Educate the patient to immediately report any fever,
increasing pain, falls, cast discomfort or sensation of wetness.
Ankle fusion is a successful surgery but does alter the
patient’s lifestyle until full healing occurs.
metal ions, the technical difficulty of the procedure, and the
possibility of a slightly greater acetabular bone resection than
with total hip replacement.
Patient selection is crucial for success in hip resurfacing.
Younger, active individuals with strong bones and
relatively normal bony architecture are prime candidates.
Contraindications include:
• Osteoporosis
• Female of child-bearing age
• Impaired renal function
• Need to alter leg length
• AVN > one-third of head
• Markedly abnormal bony architecture
Ten-year data indicates up to 99.5 percent success rate with
the Birmingham hip resurfacing in properly selected patients.
This year’s Dimensions in Cardiac Care Nursing Conference was held March 9-11 on
Cleveland Clinic’s main campus. Co-directing the 27th annual conference were Deborah
Brosovich, MA, RN, CCRN; Kelly Hancock, MSN, RN, CAN-BC; and Kathleen Hill, MSN,
RN, CCNS-CSC. This national conference provides nurses with a forum to share the
latest knowledge in the care of the cardiac patient. More than 400 nurses attend the
event each year.
Today’s healthcare consumer seeks institutions that provide
excellent clinical care and excellent customer service.
Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS), which was mandated in July 2007, has
made patient experience transparent to consumers.
Cleveland Clinic, a consistent leader in patient care and
outcomes, is similarly taking a leadership role in creating a
valued patient experience. Not only will paying attention to
the human side of healthcare create a potential competitive
advantage, research demonstrates that it also improves
outcomes, patient compliance and physician satisfaction. A
2005 study in the Journal of the American Medical Association
concluded that “communication skills and clinical empathy
have a direct impact on patient satisfaction and clinical
outcomes.”
When the elements of empathetic healthcare as defined by a
valued patient experience are considered, the leadership role
of the Cleveland Clinic Nursing Institute is obvious. These
elements include explaining the care plan to the patient,
communicating with the patient and family and supporting
their emotional and physical environmental needs as well
as the patient’s medical ones. The bedside nurse is the
individual on the healthcare team who spends the most time
Restoring Empathy to
Healthcare
M. Bridget Duffy, MD | Chief Experience Officer | Cleveland Clinic
As technology plays an ever-increasing role in healthcare, hospitals and health systems are
seeking to restore the human touch to the patient experience.
with the patient and therefore has the greatest opportunity to
practice empathetic healthcare.
Cleveland Clinic is committed to transforming the patient
and family experience in a way that creates competitive
differentiation. As the first steps in the process, mechanisms
are being created to identify gaps in the system. When
the opportunities for improvement have been identified,
programs will be created to address them and catalyze
system-wide change.
Success will be evaluated through measures of patient
satisfaction such as HCAHPS and the Call Back Program,
the number of grievances and complaints, employee/staff
engagement scores, financial performance and clinical
outcomes.
The Nursing Institute will play a prominent role in
implementing and sustaining change and will set a new
standard for empathetic care.
27TH ANNUAL DIMENSIONS IN CARDIAC CARE NURSINg CONfERENCE

27TH ANNUAL DIMENSIONS IN CARDIAC CARE NURSINg CONfERENCE
Reclaiming Our Priorities
David Hanson, MSN, RN, CCRN.CS | 2007-2008 President | American Association of Critical Care Nurses
As healthcare becomes more complex and demands on nurses’ time and
talents increase, now is the time for critical care nurses to reclaim their
priorities. Safety and quality must move to center stage in healthcare,
and nurses must be at the front of the stage.
Reclaiming priorities does not have to be complicated. It
requires that nurses first be clear regarding their core values.
Patients and families, safety, and reliability are critical care
nursing’s three non-negotiable core values.
Based on the concept of concentric circles of relationships, a
nurse’s priorities depend on the “circle” of people he or she
is occupying at the moment — the nurse and the patient, the
nurses on the unit, the entire healthcare team, the hospital
or an even wider circle. Once nurses define the priorities for
each circle, they need the knowledge and resources to achieve
them.
Nurses can apply several effective strategies to the process of
reclaiming their priorities:
• Free up energy and resources by completing one activity
before starting something new.
• When starting a new project, consider how each step
contributes to achieving the project’s purpose.
• Use planned neglect – suspend action on less critical issues
while pursuing the main goal.
• Learn from mistakes.
The goal for nurses should be to sort through all the possibilities
and focus on the priorities that support their core values
of patients and families, safety and reliability. Although identifying
those priorities is not complicated, pursuit of them
can be complicated by other factors. It is not unusual for a
nurse’s priorities related to core values to be overshadowed by
competing priorities.
Nurses must use their voices to lead the dialogue with the
healthcare team that will define their priorities within each
circle and reclaim the ones that matter. A nurse’s priorities
will shift over time, but as long as they advance nursing’s
core values, nurses can be confident in knowing that they are
doing the right thing.
The APN on an Inpatient Unit
Sandra ference, MSN, CNP | Kathryn Piccolo, MN, CNP | Cleveland Clinic
Incorporating Advanced Practice Nurses (APNs) into the postoperative care team has decreased length of stay
on Cleveland Clinic’s postoperative cardiac surgery step down unit. This model is unique in that it integrates
APNs with different backgrounds, including Adult Nurse Practitioners, Acute Care Nurse Practitioners, family
Nurse Practitioners, and Clinical Nurse Specialists, all with prescriptive privilege functioning identically in
providing care to the post-operative cardiac surgical population. The success of this model has led to its
implementation on other surgical floors.
The APN becomes involved in patient care and discharge
planning as soon as the patient leaves the CVICU. The
APN works closely with a multidisciplinary team of
healthcare professionals to improve outcomes, throughput,
communication, coordination of care, and ultimately to
reduce length of stay.
Developing a plan of care with the cardiothoracic surgeon
and cardiologist is one of the APN’s primary responsibilities,
a role that involves medical management specific to the
postoperative course as well as to other underlying medical
conditions. APNs hold legally defined decision–making
authority, reducing the need to involve a physician in many
situations. As a result, the APN is typically the first responder
to any patient event and directly manages the patient care.
In addition to having post-graduate degrees and
advanced training, the APNs must also be highly skilled
communicators. They facilitate communication among all
care providers and act as advocates for the patients and their
families, serving as the family’s contact person with the
healthcare team.
Although APNs are becoming more widely accepted,
these professionals still face considerable challenges
and limitations to their practice. Legally defined levels
of responsibility vary by state, and Ohio has been slow
to recognize the valuable role of the APN. Prescriptive
privilege is one of the main areas in which the profession
is seeking additional authority. Currently, Ohio offers a
limited formulary of medications that APNs with prescriptive
authority can prescribe. Most IV cardiac medications
can only be prescribed by Acute Care certified APNs, thus
limiting the ability of the Adult and Family APNs working
on the inpatient unit to respond to rapidly changing patient
conditions. With the help of Sudish Murthy, MD, a Cleveland
Clinic thoracic surgeon, our team of APNs successfully
petitioned the Committee on Prescriptive Governance at the
Ohio State Board of Nursing to expand the Adult and Family
APN formulary to include many commonly prescribed IV
cardiac medications that can be safely used on the inpatient
cardiac unit. In addition, the Ohio Association of Advanced
Practice Nurses has legislation that is progressing through
the state government which will expand the APN formulary to
include Schedule II medications.
The post-operative cardiac surgery APN care model provides
13-hour coverage 7 days a week, with each APN caring for
10-12 patients per day. By maintaining a reasonable ratio of
patients to providers, the APNs are able to offer personalized
care and move patients through the surgical experience in an
efficient way.
27TH ANNUAL DIMENSIONS IN CARDIAC CARE NURSINg CONfERENCE

4TH ANNUAL NURSINg RESEARCH CONfERENCE
The 4th annual Cleveland Clinic Nursing Research Conference was held May 8. Topics included navigating
through the IRB and funding process for research projects, presentations of research projects, qualitative
methodologies and quantitative research, and a question and answer session with a panel of experts.
Expert Panel Members: Christine Nelson, MSN, RN, APRN, BC,geriatric Clinical Nurse Specialist, Lakewood-Cleveland Clinic
| Chris Hummel, MS, RD, CNSD, LD, Registered Dietitian, Cleveland Clinic | Carol Dennison, MSN, RN, ACNP, CCRN, Nurse
Practitioner, Medical Intensive Care unit, Cleveland Clinic | Patrician Rosenberg, MSN, RN, Administrative Director, Detroit
Receiving Hospital, Detroit, Mich. | Georgean Krizmanich, BSN, RN, Ambulatory Nurse Manager, Pulmonary, Allergy and
Critical Care Medicine, Cleveland Clinic | Nancy May, MSN, RN, Director, Ambulatory Nursing, Cleveland Clinic
Panel Moderator: Nancy Albert, PhD, RN, Director, Nursing Research, Cleveland Clinic
PANEL DISCUSSION HIGHLIGHTS
How do you encourage nurses to do research on the unit?
MAY: We create small-group workshops to get a project started
and create the team. We also deliberately carve out time for
nurses to do research while providing the resources they
need. The small-group approach has been very effective on my
unit, but it is not the solution for every unit.
What are your recommendations for someone who has an interest
in research but the institution doesn’t have any resources?
NELSON: Tap into someone who can mentor you and help you
get started.
ROSENBERG: Replicated studies are an excellent way for the
novice to start because everything is there for you, like the
study design and tools. Then you can tease out what you are
interested in. This also gives you a built-in mentor. Replicated
studies are a great way to get your feet wet. Start with a review
of the literature to get some ideas.
How do you overcome nurse bias in research to keep your
results clean?
ROSENBERG: Talk to all the nurses up front and at the end to
educate them on why unbiased data are important and how
the results will be used. You need to be able to control bias.
We used a nurse who had been out on disability and was not
known to the unit to conduct questionnaires.
ALBERT: Unbiased data collection is essential. That means do
not use someone from your team. Without unbiased data you
cannot trust your results.
KRIZMANICH: In our studies we blind all the nurses.
What do you recommend as the first steps to getting started?
MAY: We found the small-group workshops to be very useful.
We opened them to all who were interested in research and
brainstormed ideas. Factors to consider are safety, whether an
idea is within the scope of practice and what the standards are.
HUMMEL: Research ideas are everywhere. You need to have
a leader to write the proposal and show others how to do
the work and then ultimately write the study paper. Every
discipline can get involved. It’s important to broaden our
horizons and talk to others outside our field to help us with
our research.
Transforming Your Unit from
good Enough to Excellent
gladys Campbell, MSN, RN | Executive Director, Nothwest Organization of Nurse Executives, Seattle
Nurses must make an impact at the intersection where the patient
meets the caregiver if their research is to have meaningful outcomes.
Well-planned and executed research is the path to excellence in nursing.
Evidence-based practice, currently touted as the “Holy Grail”
of nursing, is practicing according to what’s known. That’s
not excellence, that’s average.
To be excellent, nurses must stand with their feet firmly
planted in current evidence-based practice, lean into the
abyss and discover something new. In this model of nursing
practice, an effective leader is a nurse who inspires her team
to “lean into the abyss” in pursuit of new knowledge. To be
an effective leader who can facilitate this spirit of inquiry
requires charisma, a plan and a compelling vision.
An individual’s ability to make changes is dependent on that
person’s ability to influence others. Therefore, an effective
leader must be equipped with expertise and knowledge,
positive interpersonal skills and mentorship ability. An
effective leader must have the ability to get things done
through other people and learn how to balance intellectual
ability with emotional ability.
SAvE THE DATE
Striving for quality and meeting nursing standards is
important but may not be enough to achieve excellence,
particularly when a focus on the routine replaces the creative
thinking that is essential to advancing practice. Too often,
leaders become the doers of projects and the fixers of
problems when what they need to do is get their chin up and
start thinking strategically.
Nurses in leadership positions must consider one question:
what would you be doing if all the compliance work was done?
This is the central question for leaders who are trying to move
beyond competence to excellence.
Achieving excellence requires a commitment to elegant
performance measurement against evidence-based standards
and then doing something with the measures to move beyond
the standard. This is the role of research — from being
average, you lean into the abyss.
March 20, 2009 9th Annual orthopaedics:
Excellence Through Education Conference
May 1, 2009 Patricia Benner, RN, PhD, FAAN, FRCN, shares her latest
research at a breakfast presentation
May 7, 2009 Nursing Research Conference
For more information on any of these conferences,
visit clevelandclinic.org/nursing.
4TH ANNUAL NURSINg RESEARCH CONfERENCE

ET/WOC NURSINg CONfERENCE
Cleveland Clinic’s Enterostomal Therapy/wound, ostomy,
Continence Nursing celebrated 50 years of service.
The ET/WOC nursing specialty began when R.B. Turnbull,
MD, treated a seriously ill female patient with mucosal
ulcerative colitis. For her to survive Dr. Turnbull had to
remove her colon and rectum, which meant her body needed
a new path for waste to leave. He left the remaining small
bowel and created an ileostomy to allow the waste to pass
from her body through this small opening in her abdomen
called a stoma.
This stoma proved to be a life-saving procedure but the patient
required an external device to collect the waste and contain
the odor. The patient needed to wear a rubber bag at her waist
to collect her waste; the bag was attached with skin cement,
which did not hold well or protect her skin. The bag needed to
be emptied several times a day and changed frequently. The
equipment at the time was bulky and did little or nothing to
protect the skin around the stoma or contain the odor.
Despite these many challenges, the grateful patient, Norma
Gill, survived and embarked on a partnership with Dr.
Turnbull to work with him in his search to develop improved
ways to deal with this problem and help others facing this
difficult condition. Word about their work spread, which
attracted other physicians, nurses and patients from across
the United States and abroad. What began as a modest
partnership in Cleveland has grown into improving the
lives of countless patients with wounds, ostomies and
incontinence around the world.
Today, 50 years later, the Cleveland Clinic is a worldrenowned
center of ET/WOC nursing education and care.
The search for new treatment techniques continues but the
caring and compassion remain the same.
ET/WOC Nursing at Cleveland
Clinic: A History of Caring
Paula Erwin-Toth, RN | Cleveland Clinic
The Cleveland Clinic was the birthplace of Enterostomal Therapy/
Wound, Ostomy, Continence nursing 50 years ago.
From Patient to Empathetic Nurse
Some 50 years ago, a baby girl was born with multiple birth
defects. Several doctors thought she would be incontinent of
urine and stool, never walk, experience hearing deficits and be
mentally challenged. One doctor counseled her parents that
the kindest thing to do would be to allow their baby to die.
Her parents did not take the advice they received. Instead,
they did the best they could for their child and took her
to several specialists who gave them hope. Granted, there
we going to be many surgeries along the way, and she was
incontinent of urine. She did manage to walk by the time
she was four years old, however, and did not experience any
hearing problems, nor was she mentally challenged. She
experienced many kidney stones and hemorrhages along
the way and had to wear a diaper to manager her urinary
incontinence. At the age of 10, she underwent a urinary
diversion to help protect her kidneys and contain the urine in
a pouch, instead of diapers. At the time she was so fortunate
to have terrific surgeons, a wonderful, family and Norma Gill
to help her learn how to care for her ostomy.
That little girl was Paula Erwin-Toth, who today is Director
of ET/WOC Nursing Education at Cleveland Clinic. She was
mentored by and for 18 years has worked at Cleveland Clinic
with Victor Fazio, MD.
Erwin-Toth says, “Having been a patient most of my life, I
have empathy for what people are facing. If my experience,
caring, skill and support can help them cope with an ostomy
then I know the spirit and dedication of Norma and Dr.
Turnbull live on.”
Early ETs – Stoma Required!
Advantages and Challenges of the
ET/woC Nurse with an ostomy
Colleen M. Potts, RN, BSN, CWOCN | Cleveland Clinic
Colleen Potts, RN, was born at Cleveland Clinic 47 years ago,
and her entire 25-year nursing career has been at Cleveland
Clinic. Working in the areas of critical care, medical/surgery
and subacute, she joined the Department of Enterostomal
Therapy-Wound, Ostomy, Continence Nursing six years ago.
Soon after the birth of her son in 1987, Colleen was diagnosed
with severe ulcerative colitis. Her physician, colorectal
surgeon Ian Lavery, MD, FACS, removed her entire large
intestine and gave her an ileostomy. She lived with the
ileostomy for two years, returned to Dr. Lavery requesting a
reversal, but she was too overweight.
Upon losing 40 pounds, she had J-pouch surgery in October
1988 and was free of her ileostomy from April 1989 to April
1991. She suffered with constant sharp abdominal pain
during the entire time, which was a devastating period in
her life. Colleen underwent two surgical procedures to make
the J-pouch work. Unfortunately, they failed and the pain
continued. To gain a better quality of life, she decided to go
back to the ileostomy. She enthusiastically welcomed her
ileostomy back as a small price to pay for getting her life back.
Feeling grateful that she was given a second chance at a
quality life, Colleen felt a strong calling to work with other
ostomates and became an ET-WOC nurse six years ago.
A live educational program was held in April that
provided a review of state-of-the-art nursing and surgical
management techniques. Paula Erwin-Toth, MSN, RN, ET,
CwoCN, CNS, was the course director. The course was
held on the Cleveland Clinic main campus.
Assuring Others
Colleen feels very fulfilled in her job as an ET-WOC nurse.
Given her personal experience, she brings a unique
perspective to her work as a happy, healthy role model for
stoma patients.
“I am proof for people that you can live a ‘normal’ life, even
when you have a stoma,” she says. “When I share my personal
information with my patients, not only are they so grateful
but also there is an instant connection formed. Their fear of
having an ostomy is not so overwhelming, and I have given
them some relief.”
“I have a deep impact on my patients for the simple reason
that I ‘walk the walk.’”
ET/WOC NURSINg CONfERENCE

ET/WOC NURSINg CONfERENCE
Complex Wounds in Home Care
Kathy Tavernelli, RN, BSN, CWOCN, ET | Cleveland Clinic
Ensuring effective home care services for patients with complex wounds
requires good communication with the referring case manager or social
worker as well as strong patient and family support.
It’s vital to have written information on the necessary
technical tasks and, if possible, to visit the nursing facility to
meet the patient and observe the procedures. Collaboration
with these nurses is essential regarding the supplies needed,
whether they’re on the home care agency’s formulary list,
evaluating if the patient has insurance to cover home care
services, and whether the insurance pays for the supplies.
Once this is determined, the nursing plan of care may need to
be modified and tried out before the patient is discharged.
Once the patient goes home, the emphasis is on patient and
family education. The goal of successful home care is to make
the patient independent in his or her own care. If they are not
able to do so, the family must be willing to handle it.
Written instructions accompanied by photos are the most
helpful way to educate patients and/or their family. Written
instructions must be simple, readable, understandable at
the 4th-grade level and explain the wound-care procedure
step by step. Avoid abbreviations that haven’t been explained
and clearly state infection-control measures, such as hand
washing and when and how to dispose of soiled dressing and
waste materials.
Good photo documentation in the instructions will decrease
the number of on-call visits that must be made to the home
because the patient or caregiver can’t remember the steps of
the wound-care procedure. A digital or Polaroid camera can
be used, but note that the patient or family must give written
permission before any photos are taken.
While taking photos and putting together an instruction
manual is time consuming, the results are worth it. For those
patients or families who have a computer, digital photos can
be downloaded. With clear instructions, accompanied by
photos, there is less caregiver and nursing staff frustration,
and the patient’s wound/ostomy will be managed much more
efficiently.
In summary, a continuum of nursing care for the patient
can occur after numerous admissions to different facilities.
The initial plan of care begins in the acute-care setting. This
information is then relayed to the rehabilitation facility,
where the plan is modified as needed. Then the patient moves
back home and begins the process of self-care with wellwritten
instructions and photos for reference.
All these stages can help ensure a better quality of life for
patients who need complex wound care at home.
Our one-day course directed to nurses and other allied health professionals involved in the
care of urology and/or gynecology patients was held Saturday April 12. Course co-directors
were Susan Beam, RN, BSN; Brian Klein, RN, BSN, BA, CNOR; Janet Ursinyi, RN; Michelle
Suhy, RN, BSN, CURN; Patricia Young, CNP, RNC, MSN, Med; Laurel Stevens, RN, BA; and
Rita Mcfadden, LPN.
This presents a challenge to the nursing staff. Instruction
must be focused on the ability these patients have to initiate
and perform activities on their own behalf to maintain their
life, health and well being.
The goal in instructing motor-disabled patients is to
ensure that they will be able to perform intermittent selfcatheterization
with minimum assistance. There are several
helpful tips nurses can provide these patients:
• use a mirror
• adjust length/stiffness of catheter
• reverse sitting of the toilet
• touch the meatus
• void before insertion
• use a tampon in the vagina
• use a closed urinary catheterization system
Keeping the Disabled Patient
free of Indwelling Catheters
Angela Williams, CURN,BSN | Pat Young, RNC, CNP, MSN, Med | Cleveland Clinic
The urological nursing staff instruct five to seven patients in intermittent self-catheterization
(ISC) each week. Approximately 20 percent of these patients have motor disabilities that
require adaptations in the standard ISC instruction format.
It’s important to emphasize the following:
•
wash hands
• gather supplies: straight catheter — #14 french — 12” in
length, collecting leg bag, cleanse wipe and protective
bedpad
• position yourself in bed
• through touch, insert the catheter that has been attached to
the collecting bag so that the bladder empties
• wash and store supplies
• alternate with two adapted closed units
Recommendations for personal hygiene after the procedure
include:
• clean the catheter with soap and water after each use
• rinse the collecting bag after each use with both soap and
water, or with soap and water or a mild vinegar solution
Using these self-catheterization training techniques with
disabled patients leads to high patient satisfaction, reduced
urinary tract infection rate, reduced clinic visits and fewer
patient phone calls to the nurses and physicians or nurse
practitioners.
4TH ANNUAL UROLOgY-gYNECOLOgY NURSINg CONfERENCE

4TH ANNUAL UROLOgY-gYNECOLOgY NURSINg CONfERENCE
There are numerous risk factors for cervical cancer,
including:
• age at first coitus
• having had multiple sex partners
• having had a sexually transmitted disease (HPV)
• having low socio-economic status
• cigarette smoking
• being on immunosupressants (HIV, renal transplants)
• having a mother who took Des (diethylstilbestrol)
• having a history of dysplasia
Pap tests are a proven way to discover cervical cancer.
Frequency is an important factor. The ideal timings are:
• Three years after onset of sexual activity, or 21 years old
• Age 21-30 annually
• Age 30, after three normal Pap tests, repeat every 2-3 years.
(If there is a new sex partner, restart annual Pap tests.)
• S/P hysterectomy for non-cancer do not need Pap tests
• Over 70 years old — may stop if three negative Pap tests in
the last 10 years
Cancer of the cervix can present with any of the following
symptoms:
• vaginal bleeding after sexual intercourse
• pelvic pain
• pain during sexual intercourse
• unusual vaginal discharge
• abnormal bleeding during menstrual period
• heavy bleeding during menstrual period
• increased urinary frequency
Cancer of the Cervix
Linda Iannetta, RN | Cleveland Clinic
There were 11,150 new cases of cervical cancer in 2007. fifty percent of women
diagnosed are between the ages of 35-55. Twenty percent of women diagnosed are
more than 65 years old. Cervical cancer occurs most often in Hispanic women. Black
women develop this cancer 50 percent more often than non-Hispanic women do.
There is a 92-percent, five-year rate of survival if it is discovered in the earliest stage.
for all stages combined, the overall survival rate is 72 percent.
There are four stages of cervical cancer. In Stage I, the tumor
is still confined to the cervix. The tumor has spread to the
vagina and neighboring tissue in Stage II. In Stage III, the
tumor extends to the pelvic wall, and by Stage IV, the tumor
extends beyond the pelvis.
Effective treatment depends on the stage of the cancer.
Radiation therapy is used in Stages IB through Stage III. In
Stage IV, the treatment consists of extended field radiation
therapy and chemotherapy.
Preventive measures include getting a regular annual Pap
test, avoiding exposure to HPV, delaying the onset of sexual
activity, limiting the number of sexual partners, avoiding sex
with individuals who have had many other sexual partners,
not smoking. Condoms can provide some protection. Two
vaccines — Gardisil ® and Cervarix ® — are available to prevent
cervical cancer.
Ultimately, despite advances in screening, cervical cancer
remains a significant problem in underserved populations
worldwide. Improved understanding of this disease has
enabled more conservative treatment of select early-stage
patients. Chemo radiation for advanced and high-risk cervical
cancer has had a significant impact on survival. This has
become the new standard.
Improving Clinical Outcomes in Renal Cancer
Laura Woods, RN, MSN, OCNN | Cleveland Clinic
In 2007, renal cell carcinoma (RCC) accounted for 2.5 percent of all
cancers, with a median age of 60 years. There were 51,190 new cases
and 12,890 deaths that year. The incidence of renal cancer at all stages
has steadily increased since 1973. Unfortunately, increased detection of
earlier-stage disease has not coincided with a decrease in the number of
patients diagnosed with advanced renal cancer.
Diagnosis of renal cell carcinoma frequently occurs at
advanced stages, severely limiting the success of treatment,
and median survival is barely more than a year. Treatment
of renal cancer was previously limited to nephrectomy
or immunotherapy (interleukin or interferon), which
was effective in a small subset of patients but was often
accompanied by severe side effects.
Immunotherapy — Interleukin-2 and Interferon — have been
available since 1992. Targeted therapies block or interfere with
signaling pathways that carry messages from the cell surface
to the nucleus that control tumor vascular supply and tumor
cell proliferation. Vascular endothelial growth factor (VEG-F)
stimulates the development of new blood vessels (tumor angiogenesis)
which bring nutrition and oxygen to tumor cells,
increasing the tumor’s ability to grow and metastasize.
Mammalian target of Rapamycin (m-TOR) is an important
regulator of cell proliferation and survival. Increased m-TOR
activity leads to increased levels of VEGF and promotion of
angiogenesis. PDGF and RAF are two additional pathways
that are important in angiogenesis and tumor growth in renal
cancer and other cancers. There are now several targeted
therapies approved by the FDA and others in the investigational
stage:
FDA approved
® • Sorafenib Nexavar (Bayer/Onyx) VEGFR, PDGFR, RAF
® • Sunitinib Sutent (Pfizer) VEGFR, PDGFR
® • Temsirolimus Torisel (Wyeth) mTor inhibitor
Investigational
® • Bevacizumab Avastin (Genentech) targets VEGF ligand
® • Axitinib (AG-0-13736) targets VEGFR, PDGFR
® • Everolimus (RAD-001) targets mTOR
These treatments are not chemotherapy. They target a signal
transduction pathway. Therefore, administration and side
effects are different from chemotherapy.
Sorafenib is the first tyrosine kinase inhibitor approved for the
treatment of advanced renal cell carcinoma. Nursing assessment
and inventions are critical for effective management of
unique side effects, including hand-foot skin reaction. Effective
side-effect management enables patients to maintain the
therapeutic benefit and maximize their quality of life.
Sorafenib, sunitinib, and temsirolimus have demonstrated
effectiveness for patients with metastatic renal cancer.
While surgery remains the only curative treatment for a
limited number of patients, these new therapies slow the
rate of disease progression for many patients. By slowing
the progression and metastasis, patients are living longer,
experiencing better control of disease-related symptoms, and
are able to continue working and enjoying family activities.
Clinical trials are continuing to evaluate these agents in
various clinical settings and in combination, with additional
therapies being developed for incorporation into the
therapeutic options for renal cancer.
These targeted pathway medications can result in numerous
side effects and areas that require special attention. Side
effects vary in their incidence and severity for each of the
targeted therapies and may become chronic in nature, requiring
ongoing nursing assessment and management. Potential
side effects may be gastrointestinal and dermatologic, and
may include fatigue, hypertension, myelosuppression, and
hypothyroidism.
When using emerging treatments for patients with RCC,
nurses play a key role in providing effective patient education
to ensure correct dosing and administration of oral therapies
and ensuring compliance with treatment and early interventions
for side effects, which will ultimately maximize the patient’s
benefit from these novel therapies.
4TH ANNUAL UROLOgY-gYNECOLOgY NURSINg CONfERENCE

Notable Nursing clevelandclinic.org/notable
An Evaluation of Nurses’ Knowledge
of Diabetes Survival Skills
Study shows need to re-evaluate how nurses
are taught about diabetes management
Diabetes continues to dramatically increase in America. The Centers for Disease Control (CDC) announced this
past June that 24 million Americans now have diabetes, an increase of 3 million people in just two years.
866.219.7149 Fall 2008
Nurse of Note
Little did Robin Kruger, RN, BSN, know that she
would become a nursing pioneer at Cleveland Clinic
when she came on board more than 23 years ago.
She initially worked in Inpatient Pediatrics for two
years and then spent five years doing triage in the
pediatric and adult ambulatory clinics.
Robin Kruger, RN, BSN
As for being a Cleveland Clinic nursing pioneer, Kruger She ultimately found being a nurse on call extremely satisfy-
While Certified Diabetes Educators teach individuals with The research study consisted of a 20-item true/false
worked on July 14, 1991, when the first calls came in to
ing. “Knowing that people have somewhere to turn, and we
diabetes, it’s vital that nurses who treat conditions in people questionnaire that assessed nurses’ knowledge of diabetes
the Nurse on Call hotline. This innovative new program can help them is a good feeling. Calming people down is an
with diabetes also understand the intricacies of diabetes survival skills. Nurses were queried about their comfort in
was established to provide community access to health
important part of what we do,” she explains. “We sometimes
management and teach patients how to manage their
administering insulin and oral glucose lowering agents,
information from registered nurses.
get calls in the middle of the night from people who have a
24
condition.
“With recent advances in technologies and new medications,
effective diabetes management has become more complex,”
says Mary Beth Modic, MSN, RN, CNS. “Nurses must keep
abreast of advances and education survival skills needed
performing blood glucose monitoring and teaching patients
about symptom management. In addition, nurses were asked
to provide information about their participation in recently
completed continuing education classes about diabetes and
diabetes-related topics.
Kruger played an integral role in the planning and implementation
of the Nurse on Call program. “It was exciting to be
in on the ground floor of this new area of nursing,” she says.
“There were only five of us initially, we staffed the phones
seven days a week — from 7 a.m. to 11 p.m. — and we handled
screaming baby, and we’ve had many serious emergency calls
we’ve had to refer to 911.” The nurses also help frustrated
calls navigate through the Cleveland Clinic’s system.
Working at Nurse on Call caused Kruger to have a major
epiphany about nursing, she says. “I came to the conclu-
25
to teach patients before hospital discharge. This can be
Overall, nurses’ scores reflected poor knowledge in all areas
40,000 calls in the first year. We take all the calls directly, sion that there’s more than one way to be a nurse. You don’t
daunting, especially for nurses whose primary patient
studied, Modic reported. Nurses scored highest in symptom
with the same nurse handling each
have to be at a patient’s bedside.
population is medical or surgical conditions other than
management and lowest in diet management. Nurses with
call from beginning to end,” she quote
Some people think you’re not a nurse
diabetes/diabetic complications.”
less experience had a lower total score than nurses with two or
explains. Nurses became accessible
because you’re only talking to people
Ninety staff nurses were recruited by Clinical Nurse Specialists,
nurse managers and nurse researchers over a threemonth
period to assess nurses’ knowledge of diabetes education
principles for diabetic patients who were admitted with a
more years of experience. There was no significant difference,
however, in scores among nurses who attended educational
diabetes programs and those who did not.
“These results demonstrated a serious need to re-evaluate
around the clock every day in 1992
when coverage was expanded to
three shifts.
“While we provide health informa-
“It was exciting to be in on the
ground floor of this new area
of nursing.”
on the phone. Nothing could be further
from the truth,” she notes.
After 17 years of operation, the Nurse
on Call program is now staffed by 30
medical cardiovascular condition or who had cardiac surgery. how we educate nurses, both in nursing school and in
tion and education and physician
registered nurses and growing. The
The study consisted of three specific goals:
continuing education courses, about diabetes management
and diabetes survival skills,” Modic explained. “In addition,
referrals to the community callers,
today the majority of our calls come
program is on target to handle more
than 300,000 calls in 2008. Kruger
1. Examine nurses’ knowledge level of diabetes surviv- there may be a need to re-examine what information diabetic
from the patients of Cleveland Clinic physicians,” Kruger ex- estimates that roughly 60 percent of those calls are symptom
al skills, including oral and injectable medications/ patients receive about diabetes self-care when they are in the
plains. “We do symptom-based triage, asking callers a series based, with about 30 percent physician referrals and 15 per-
medication administration, diabetic diet, managing hospital for another medical or surgical condition. It may be
of questions to determine the urgency of their condition and cent for health information.
signs and symptoms of hypo or hyperglycemia and
blood glucose monitoring.
that nurses are challenged in educating themselves and their
patients when diabetes is not the primary diagnosis.”
then direct them to appropriate care.”
Beginning as a staff nurse, Kruger served in multiple roles
2. Examine nurses’ comfort level in teaching patients
about survival skills.
How much impact this has on complications and postdischarge
outcomes is not well understood. “Because nurses’
Kruger initially had reservations about switching to this new
concept in nursing. “I really loved the face-to-face interaction
with patients, and I was very concerned I’d miss that aspect.”
during her 17-year tenure at Nurse on Call. She was appointed
the Nurse Manager of the program in February 2008.
Email comments to krugerr@ccf.org.
3. Explore variations in the knowledge and comfort levels knowledge and comfort levels were less than optimal, this
in nurses, based on nurse characteristics.
research has empowered us to look forward and be innovative
in designing both educational modalities and redefining
survival skills,” Modic added. “Ultimately, we must meet the
educational needs of patients with diabetes when they are
hospitalized.”
Email comments to modicm@ccf.org.

The Cleveland Clinic foundation
9500 Euclid Avenue / AC311
Cleveland, OH 44195
We will be hosting our semiannual nursing open house
in spring 2009. For more information, contact Mandy
Barney at barneya@ccf.org.
weekend visit Program
our weekend program offers the perfect chance to get
an in-depth look at the exciting career opportunities we
offer at Cleveland Clinic’s main campus, to meet our
nursing staff and also to experience Cleveland. we hope
you’ll invest some time with us. we promise it will be
time well spent!
Highlights:
• Receive a complimentary stay at a hotel near our
campus
• Enjoy lunch and dinner on us
• Discuss employment opportunities with a nurse
recruiter
• Receive an on-site job interview
• Participate in a guided tour of the Cleveland Clinicmain
campus
• Shadow a nurse on one of our inpatient hospital
units
• Explore Cleveland’s nighttime attractions
To be eligible, you must:
• Be a registered nurse or senior nursing student
• Live at least 75 miles away from the Cleveland Clinic
• Be willing to relocate
• Be interested in working on a medical, surgical,
cancer center or cardiac hospital nursing unit at our
main campus in Cleveland, ohio
The weekend visit Program is scheduled for the 3rd
weekend of each month. Additional dates are available
for groups of 4 or more.
For more information, please call 216.448.0300.
visit clevelandclinic.org/weekendvisit to register and
apply online.