“We Don’t Care What’s On Your Head. We Care What’s In It.”

So there’s this thing in Quebec which I’m sure my Canadian readers have heard of and maybe also a few of my American readers, which involves the Quebec government devising some legislation called the Charter of Quebec Values. I have to say “charters” and “values” are nice happy positive words, and Quebec is filled with deliciously cheesy poutine, hockey, maple syrup, and those devilishly sexy Québécois men, so what’s there not to like (except for les Habs, boo, hiss!)?

The thing is, this Charter of Quebec Values wants to ban wearing obvious religious symbols for all public employees, including nurses and other health care professionals. This, I have to say, has ABSOLUTELY NOTHING TO DO with some nice Ladies of Muslim persuasion cheekily wearing hijab in broad daylight in Montreal and everything.

From the Government of Quebec website. Top: acceptable. Bottom: Va te faire foutre (You can Google Translate that too.)

(Just so you know, American readers, I must also officially tell you is NOT racist, and the fact the proposed legislation targets Quebecers with brown skin is merely, um, an unfortunate coincidence.  We say this because the Quebec government is acting from the purest, noblest of intentions. This is a Fact, because the Quebec government has told us so. (You can Google translate it or something.) It is well-known that the separatist, ruling Parti Québécois has long been offended by clerical collars, Jewish kippahs, wimples and garish Roman Catholic crucifixes. This is also a Fact, which you can also Google.)

The proposed charter will affect health care professionals, including nurses. My question, then, does the wearing of religious symbols or associated clothing have any place in the provision of health care? Should nurses don hijab on the hjob?

Before you run off to start raving, maybe you should consider a few things. First, banning headscarves (or whatever) has a distinct element of authoritarian nastiness about it. Should the nursing profession be that coercive? There’s probably no getting around the fact that if the legislation is passed, it will be nurses enforcing the ban against other nurses.*  (The irony of having the Quebec government telling Muslim women how to dress, partly, it is argued, to ensure gender equality, is beyond these guys.)

Another thing: nurses have a long history of wearing weird things on their heads. It’s safe to say that if you look over the course of the history of nursing, no crazy headgear has been the exception, not the rule.

Like this:

Or this:

Or this:

Which reminds me: some of you might say, oh it completely different! it’s a religious thing! Muslims shouldn’t be pushing their faith in our faces!

Well, there’s this:

+

And this:

But not this? (Love this ad, by the way. It was created in response to the proposed Quebec law..)

So if you’re offended by women in hijab but not by Catholic nursing sisters, what’s the difference? Do you really believe the hijab (or any other piece of religious accoutrement) sucks out the nursing from the nurse?

So dear readers, hijab for nurses and other health care professionals, yes or no?

____________

*The Quebec nurses union, FIQ, has courageously taken the position of taking no position at all. In other words, the union won’t defend members running afoul of this law. I’m pro-union, but holy Sam Gompers, sometimes their leadership are dumb as stumps.

Best. Comment. Ever.

Blog reader “Sarah” REALLY gave me a big old can of whoop-ass when she wrote something on my blog post “The Value of Nurses” She really schooled me! So take it away “Sarah”!

Nursing is critical to patient health and recovery. Nurses are responsible for the day to day care of the patient. 

Nurses are also useful for disease prevention and chronic disease management (trust me, MD wants to go to school 12+ training in the medical model of care to tell fat Type 2 diabetics they need to stop eating pie).

That said, yes nurses know how to do all the technical things listed. Respiratory threrapists [sic] can also expertly read EKGs, blood gases, and recognize heart sounds. As can paramedics. These things alone are not rocket science.

Nurses are never trained in pathology using the medical model of care to form a differential diagnosis of disease. Otherwise they’d be unhappy underpaid junior doctors. Try calling a nurse a para doctor and see what they say. Nurses seem to forget that the nursing model of care and training is a different role from MDs.

Sure nurses save lives and do some great things providing care for patients, but many other jobs do as well. Personally, if I have a disease, I’d be putting all my money into the MD/PhD in the lab trying to cure me vs a “good” nurse. I find most nurses can provide basic care but anything advanced is rightfully over their training. Good nurses recognize their limitations, not toot their own horn. So I gave up expecting competent nurses while in the hospital.

Yay so you can recognize a cardiac cycle or a hypoglycemic attack in your patient (how did you let the patient get that way in the first place?!). That still doesn’t mean you have knowledge worth $40 hr+.

Well Sarah, you are absolutely right. I was thinking just the other day about the time me and Doreen were sitting in the Resus Room playing cribbage for a nickel a point when Greta from Admissions walked by and said to us, “Hey, that monitor had some funny pointy lines.” We looked up and yep, she was right! So we talked it over— I was five dollars and two bits ahead — and we thought since he — the patient, I mean — was maybe in ventricular tachycardia we should call in Dr. Handsome. So we did and all of a sudden there was this big fuss, Dr. Eagerpants and Dr. Contentious and Dr. Fusspot came running in and started doing IVs and xrays and EKGs and catheters and everything. It was just like that TV show, House. Then I skunked Doreen and she got mad and left without paying me my five dollars and twenty-five cents which was now eight-fifty, and also the patient died. Dr. Handsome said sadly, “If only someone knew how to do an emergency cardioversion, we could have saved him!” and pounded his first on the Resus Room desk, just like on House. Haha. What a dummy! Like nurses can do anything like that!

Then there was the time Doreen and I were painting each other’s nails in Exams, and one of those nosey housekeepers told us the guy in bed 4 was throwing a seizure or something. And despite our wet wet nails we went over and looked and Doreen said he was! Then he stopped. I found out later he died. I guess he did something called, um, sounds like asparagus but isn’t. Dr. Handsome came in, and pounded his fist on the desk again. “If only someone knew how to give a benzodiazepine and also protect his airway we could have saved him!” he said. Doreen and me just looked at each other. What??? Nurses can do that??? But anyway I had to pee. I think on reflection we fell down a little on that one and definitely didn’t earn our $40+ an hour!

There are some other things too, so yes you are right, nurses should stick to wiping bums and leave the real doctoring to doctors, though RTs and paramedics can do some doctorings too sometimes. I will toot my horn though just a little, though! I once found some old lady had a fever once! So that was awesome!

Also, I once told a fat man with the diabetes he ate too much pie. Isn’t that kewl??? It’s like we psychically share a brain! But maybe you have it this week!

Thanks for writing!

Where does the Rot Start in Nursing Home Abuse?

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Let’s take a look at the Mission and Values statement of the nursing home:

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

Living
St. Joseph’s at Fleming is committed to creating a healthy living and working environment that:
[. . . ]

• Treats people with fairness and social justice

[. . . ]

Learning
St. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

Caring
St. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness 
• Integrates best practices and innovative solutions
• Promotes individuality as well as personal and spiritual growth 
• Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients?  How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?

Yes.

The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

A Blogger, Allegedly

So, it’s been awhile, eh?

It was Chuck Norris who found me.

To everyone who emailed and texted and Tweeted, thanks. Everything is hunky and dory. I’m not dead, ok? Let’s get that out of the way. Nor am I afflicted with a Chronic Debilitating Illness, unless you count members of my family. (That would be the topic of long separate blog post + extended psychotherapy.)

So what happened? Much to my surprise and amazement (and frank gratitude if truth be known) I got a new job about this time last year. A job with a very steep learning curve and a fairly cool boss with an alphabet soup of letters after her name and about as far away from Emergency nursing as you can imagine without leaving the hospital.

It is true, friends.

I have walked away from the front line.

I have drunk the mystical Kool-Aid.

I am Management.

But not real Management. I don’t actually manage anyone. I make up PowerPoints (ugh), give talks, and do research. I write policies. I have projects. I educate patients and staff.  I occasionally make recommendations to Important People many steps above my pay grade, When I do speak, the senior administration actually pays attention and sometimes will do this or that based on the words flowing out of my mouth. This is a bit of a revelation for a front-line nurse used to managers halfheartedly and reluctantly paying attention. OK, not really paying attention at all.

Nurse K once suggested to me that my ambitions for real management were probably misplaced. Having observed front-line managers from the other side up close for the past year, I have to agree. Being a front-line manager truly and deeply sucks. It’s far worse than being a charge nurse. (I say this as an embittered former old charge nurse, remember.) Awesome amounts of responsibility and no actual power. And navigating the snakepit which is hospital politics. And the risk of being walked off the property at will. Great job, right?

So first lesson: I think I dodged a bullet there. I really don’t want to be a manager.

Second lesson:  This is the first job where I use all of the skills I have acquired as a nurse in a meaningful and effective way.

I’m not just talking about clinical skills, or therapeutic communication skills which are surprisingly important in my current position; I’m also talking about evidence-based practice, critical thinking, leadership, understanding hospital processes, effecting change, teaching and developing clear presentations and a whole pile of other stuff — a whack of skills I acquired along the way in my ED practice.  The unfortunate fact is, the opportunities to develop and use all of these skill in front-line practice is limited. The fact I had to leave front-line practice to fully explore them is a telling, don’t you think?

Third lesson: Make the jump. I’m looking at all of you who think there must be more. Or better. Do something different. You won’t regret it.

Curiously enough a couple of days ago, someone named Darren Royds left this comment on one of my blog posts:

You need to get out and find a decent job. Have a life , live and reduce stress. I have quit nursing and was the best decision I ever made. You will end up as so many do.

Well exactly.  I haven’t quit nursing, though. But as much as I loved working in the ED, it was clearly time to move on. It was the best job decision I have ever made.

Have you guys ever made a career change to/from/within nursing? Was the outcome good/bad/indifferent?

 

 

P.S. So what about the blog?

That, dear friends, will be a topic for another blog post.

Those Nortriptyline Blehs

Nortriptyline, according to Wikipedia,

is a second-generation tricyclic antidepressant (TCA) marketed as the hydrochloride salt under the trade names Sensoval, Aventyl,Pamelor, Norpress, Allegron, Noritren and Nortrilen. It is used in the treatment of major depression and childhood nocturnal enuresis (bedwetting). In addition, it is sometimes used for chronic illnesses such as chronic fatigue syndrome, chronic pain and migraine, and labile affect in some neurological conditions.

A few weeks ago I had a fall (when it comes to falling down, I’m a Viking) which exacerbated an old injury from another fall — bottom line, was in a considerable amount of pain, and what was worse I couldn’t sleep becuase of the pain. So after about a week of sleeplessness and overdosing on AC & C, I finally gave up and went to  my GP. She prescribed some wicked bad-ass anti-inflammatories, and she also suggested I try nortriptyline. Besides being a rather dated anti-depressant, nortriptyline has some pretty nifty pain-control properties as well as the ability of  inducing sweet, restful sleep.

And, I must report, it worked amazingly well for the last couple of weeks. I’ve been sleeping like the dead, the pain is far, far better now, and I can function normally — sort of. Aside from a dry mouth, I’ve had no physical side effects at all.

Take two of these, and your ability to snark will vanish

But there’s this: nortriptyline, as I mentioned, is an antidepressant and mood stabilizer, and I guess I would describe my mood over the last week or so as tranquil, sedate, calm, unstressed, cool, placid, and serene to the point of having to check my pulse for a heart rate. Part of this new found attitude of repose is being completely demotivated to do anything creative at all, including any writing. For the last two weeks I have opened up the blog utility, fooled around a little, and after a half-hour, said, “Meh,” and went back to playing Words with Friends.

It’s plainly obvious, at least for me, having some emotional friction and turbulence feeds the creative daemon. It prods me to write, and I would guess this is true for most people who think of themselves as creative. So an interesting question: at what point would you sacrifice creativity for pain control — or relief of any condition, especially if it’s central to who you are as a human being? And on a larger scale, if everyone is medicated (it seems) for everything, what is it doing to culture as a whole?

Fortunately for me, I’ve finished the nortriptyline. It was a temporary thing. We now, as they say, return to our regularly scheduled moodiness. But here’s the thing: when I was on the drug, not only was I completely uninterested in writing, I didn’t care whether I was writing or not. The fact I could throw over something which I’ve done daily (in one way or another, even if I have written a couple of lines) for nearly three years is remarkable.

Privacy, judgment and ethics aside, I have caring to do.

A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could.  I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.

I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby.  Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.

I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby.  I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before.  Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.

Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

• tell all the kids don’t fight and play nice

• fix boo-boos

• give hugs as needed, or tissue

• make sure all the kids get lunch

• find things

• repair broken toys

• clean up little “accidents”

• greet guests, and ensure they’re fed and comfortable

• make sure everyone keeps the place tidy

• assign chores

• deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

Treat the Patient Not the Disease

Abscesses and wounds, and especially abscesses and wounds which are infected, suppurative, purulent, and generally awful, are embarrassing for patients and difficult for nurses. Embarrassing for patients because they are disfiguring and smell badly, and difficult for nurses for really the same reasons. Personally I don’t mind caring for and treating wounds and abscesses, but I know plenty of nurses who would rather throw live kittens on a hot barbecue than go anywhere near a draining carbuncle.

Jennifer Olin over at RNCentral has an excellent blog post on caring for wounds. The first part of her post deals a little with the pathophysiology of wounds, the second on the providing good care to patients with wounds. Olin writes:

Well, we are likely the healthcare providers who will first notice the problem. It will be during a dressing change, or just when you enter the patient’s room—you know. The scientific side of nursing will to clean the wound, inspect it, chart it, and if it is bad enough, inform the wound care team or physician. But remember, I said you are likely the first healthcare provider to notice. Trust me, the patient already knows.

This is where the nurturing side, the compassionate side of nursing is brought into play. And, it’s not for the weak of stomach or, particularly, the weak of heart. Bad smells carry a social stigma along with the health hazards inherent in the wound itself. Wet, sticky, bandages are a sign for all to see that there is a problem. People with wounds in this state often suffer inhibited work, social, and sex lives and frequently have feelings of shame and depression.

[SNIP]

You learn little tricks to help you not react (breath through your mouth, use a minty lip balm).  Keeping the patient engaged is the key. Many of them won’t look at their wounds, won’t acknowledge there is a problem, or want to discuss it. You can teach them how to clean and dress their wounds, give them pamphlets and supplies, and help them plan future appointments but it is the emotional part of nursing that will often make the biggest impact on their healing and wellness.

Something we (remember?) were all taught in nursing school was the holistic care of the patient, that is, caring not only for the physical complaint of the patient, but also for the emotional, spiritual, social and even economic needs of the patient. Good wound care exemplifies nursing care in a microcosm. So when nurses see a patient with a decubitus ulcer, what do they see, the wound or the patient? Our inclination, of course, is to see the wound, somehow detached from the person bearing it, a way of thinking exacerbated by seeing nursing as a series of tasks to be completed rather than a holistic process involving critical thinking. Olin’s article, in this context, is a good reminder that in the end, we should be treating the patient, not the disease.

A Note about Alan Sullivan

Nearly two years ago, the poet and blogger Alan Sullivan died. His final project, a new translation of the Book of Psalms, has been published. The translation can be ordered here. His collaborator and advisor on this translation, Seree Zohar, was kind enough to send me a note to tell me this, and to gently correct my impression — as I wrote in my post about his death — that the work remained unfinished. Sullivan, in fact, completed the translation in the very last days of his life, and I am glad to make that correction.

More on Alan Sullivan as poet is found in this brilliant tribute here.

Generation Gaps

I recently took a course with nurses of varied years of experience and ages, but it was primarily made up of fairly new graduate nurses within the last year or two. During one lecture the facilitator was speaking about the future of nursing and how we need to address the current issues and challenges that exist in the nursing profession today, and asked the class to outline a few. Issues such as the global nursing shortage, heavier workloads, lack of education support, feelings of little public appreciation and individual unit situations were brought up. One nurse felt that on his unit there was a large divide between the older senior nurses and the new junior staff. This perked up my ears. He felt that the senior nurses were threatened by the amount of theory and knowledge that he and his fellow junior colleagues had and insinuated the senior nurses felt the juniors were going to take their jobs or roles on their unit. He continued to say that the generational and differing nursing requirement (degree vs. diploma) issues existing on his unit put a huge divide between the younger and older staff. (*disclaimer* While yes, I have written about how nurses can eat their young, I disagreed with the standpoint he took.) It’s terrible to think this is happening, and despite what I have written (that is only a handful of nurses FYI, by no means the picture of the entire Acme Regional ED senior staff in the least) I personally find that there is a great blend of ages and levels of experience within my unit personally.  He stated that perhaps the junior nurses should be on their own line with the senior nurses on another. I cringed at the thought of that. For any unit to run effectively and safely it is in my opinion, which I am almost positive would be shared with most, that there needs to be senior staff at all times. A line of strictly junior staff would be unsafe and potentially detrimental to patient care not to mention the amount of issues, disagreements and incidents that could and would arise. I think of inconsistencies in care and the potential for a patient’s change in condition to be overlooked simply due to inexperience until too late.  I have found that the novice and senior staff continue to learn from each other as each are on different ends of their careers with different types of knowledge to share.  This nurse went on to say that maybe the senior staff needs to go in for remedial courses to be brought up to the “standard” of the new grad degree nurses. *insert shocked look on face*. I nearly fell off my chair. If the experienced diploma nurse does not want to go for their degree how and why could one be forced to take theoretical courses that in my mind, often have little to no benefit to the patient at the bedside. I relayed my personal opinion that the diploma nurses he is suggesting should go for remedial courses to be “brought up to speed” in fact had far more clinical time as students than any of us degree nurses and as a result were far better prepared going to the bedside when they graduated as opposed to us. I reminded him of the amount of papers and classroom time we spent talking more about nursing than actually doing it. I could write a 10 page paper on how to properly sew an emblem on a jacket with 4-5 APA references if I was asked to (please no one ask me) as a result of the amount of theory referencing involved in the degree program. This nurse’s sentiments about how degree nurses are far more qualified to be at the bedside than the diploma nurses and generation gaps exist out of jealousy or by being ill prepared made me question what sort of nonsense he was spoon-fed upon his obviously very successful graduation from a degree program. I am the product of the degree program but I do not endorse the structure of degree nursing program, at least not the one I was in. I think I should have been at the bedside far more than I was. I had yet to give an IM injection to a real patient until I was consolidating in my final 4^th year placement. I had however written an excellent 25 page paper on nursing leadership and how to effectively determine who should get Christmas vacation with examples of different leadership skills, roles and suggestions on effective management.. *insert vomit sound*. I suppose however it can depend on what one wishes to do with their career and the direction they want to take it.

Ultimately what I am trying to get at is while I am sure generation gaps exist on units, I do not believe it is entirely as a result of degree vs diploma more than it might be just personality related. Differing maturity levels, different interests, and people at different points in their lives not to mention the obvious that we are all individuals.  I enjoy working with the tough take no nonsense 15 year nurse as much as I like working with the 35 year veteran nurse who still gives every patient a bed bath and the novice 2 year nurse who wants to learn about every patient condition possible. A few of my closest coworkers have nearly 10+ years on me with a couple who could even be my parent.

Gaps exist only if we let them and really, we are not here to make friends. When we do that’s great, however, we have a job to do. If that 25 year nurse doesn’t like me, she at least knows I can get an IV on a 5 day old on the first poke and that’s all that matters. We often forget how our “issues” can affect the patients.

So i ask this, do generation gaps exist on your units? If so, are they related to degree vs diploma nurses or more just due to differing personalities and individuals at different points in their lives? Do you find yourself getting along with the nurses of the “opposite” generation?