Archive for January, 2011

I’m New. Please Be Kind.

We have all been there. We all know the anxiety. The first day in a new unit. Remember? The uncertainty. The expectations. Will they like me? Can I do the job? You feel like all eyes are on you. And there’s nothing worse than the hostile stare, or worse, the indifferent silence. The Muse RN wrote about the newbie nurse phenomenon on her blog a couple of weeks ago. Her take is that nurse newcomers ought to keep their heads down, bribe the old birds with baked goods, smile a lot, and above all, shut up. “You are here to learn our ways, not the reverse,” she writes.” You were chosen from a handful or more of others to join us – don’t make us doubt our hiring abilities by becoming obnoxious about ‘how you do it.'”

My own perspective is a bit different. It’s obvious that new (to the unit) nurses need to adapt to local norms and mores, and the initial time of employment is inevitably a time of socialization and formal and informal evaluation. But remember, the new nurse on the block is sizing up you. He’s seeing how you and your colleagues are going to treat him, and whether you all live up to the hype. So it’s a two-way street. I would probably go further and say that the onus is with the nurses on the unit to make sure the new hire’s transition is smooth.

I say this for some simple, self-interested, pragmatic reasons. Unit cohesion and teamwork means better patient outcomes, and making a new nurse “pay her dues” is probably not the best way to go about it. What’s more, every unit wants low staff turn-over and a cadre of experienced nurses taking care of patients. The time to ensure new hires are successfully integrated into a unit is in the first few months of employment. A nurse who is treated poorly on arrival by his colleagues — and we have all seen it — will remember the slights and insults for a long time. She will fulfil all your expectations of bad behaviour and bail at the first opportunity. Is that really productive? Do you want to be known as the unit that eats all the new hires live?

I speak here from personal experience, as you might guess. I was thinking of the times I was the new nurse, and I came up with a little list, some thoughts to consider from when I was in the position of being the newest colleague.

Take the time to welcome me. Really. It makes a big difference and doing so (or not) may shape our working relationship for years.

Make a point in including  me in outside-work activities.

Remember I came here because I heard this was a great place to work. Don’t disappoint me.

Whether I am an old nurse with years of experience and perspective behind me, or a new grad with up-to-date knowledge of best practice, I have something to contribute. Don’t dismiss me because “that’s not the way it’s done here.” Consider your opportunity to learn from me is as great as my opportunity to learn from you.

Acknowledge my existence.

Treat me collegially, not like some not-quite-bright child. Don’t talk down to me, and don’t be patronizing or condescending. Remember, I’m an RN, fully qualified and a professional who deserves respect and courtesy, just like you.

Cut me some slack if I don’t have the routines down right away. You’ve been here for years. I’ve been here a few days.

By the same token, don’t roll your eyes at me if I can’t find that special epidural needle the paediatrican prefers.

If I seem to make a lot of suggestions about improving conditions or processes, have the insight to realize I’m still in the honeymoon phase, and still new and enthusiastic. Or better yet, take advantage of that enthusiasm. Get me to sit on a committee, or work on a special project.

Bottom line: be kind and act with empathy and insight. Be nurses. If you don’t remember, being the new nurse on the unit is a lot harder than you dealing with the minor annoyances they create.

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Having a Mental Illness Makes You a Security Risk

This is just disturbing:

When Lois Kamenitz arrived at Pearson International Airport in November, hoping to board a flight to California, she was stunned to learn that U.S. border officials were barring her entry. The reason: Years ago, she attempted suicide.

The 64 year-old Toronto woman was fingerprinted and photographed. She questioned the U.S. Customs and Border Protection officer about how he accessed her medical records. He said he didn’t. Instead, he knew police had attended her Toronto home in 2006 because she had done “violence to self.”

[snip]

How and why her personal information was passed to a foreign government is extremely troubling, say advocates for civil rights and the rights of psychiatric patients, who believe Kamenitz’s privacy rights were invaded.

It’s not an isolated incident, says Ryan Fritsch, legal counsel for the Psychiatric Patient Advocate Office. He has heard of about eight similar cases in the past year, all involving non-criminal contact between police and people with mental health issues — records of contact that end up at the Department of Homeland Security.

Considering 20% of Canadians will have a mental illness during their lifetime, the direct and indirect costs to the economy, and the stigmatization that presents a serious barrier to care and treatment, further demonization of the mentally ill by labelling them as a “security risk” hardly seems helpful to anyone. Supposing you suffered from depression, and your employer sent you across the border on a regular basis. Would you take the risk of disclosing your depression if it would end up in the hands of government agents who may or may not arbitrarily deem you a risk?

The confidentiality/privacy issue is a whole other matter. Suffice to say, you get the feeling any meaningful protection of personal information is probably a sham, and if you care about such things, you should disclose such information bearing that fact in mind.

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Favourite Poems XXX: Carl Sandberg Times Two

Two poems by Carl Sandberg. I wonder at the ambiguity of “Monotone.”

Under the Harvest Moon

UNDER the harvest moon,
When the soft silver
Drips shimmering
Over the garden nights,
Death, the gray mocker,
Comes and whispers to you
As a beautiful friend
Who remembers.

Under the summer roses
When the flagrant crimson
Lurks in the dusk
Of the wild red leaves,
Love, with little hands,
Comes and touches you
With a thousand memories,
And asks you
Beautiful, unanswerable questions.

 

**********          **********          **********

 

Monotone

The monotone of the rain is beautiful,
And the sudden rise and slow relapse
Of the long multitudinous rain.

The sun on the hills is beautiful,
Or a captured sunset sea-flung,
Bannered with fire and gold.

A face I know is beautiful–
With fire and gold of sky and sea,
And the peace of long warm rain.

— Carl Sandberg

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Jenny McCarthy Body Count

Jenny McCarthy, of course, is the very public face of the anti-vaccination movement, which centres around spurious and fraudulent claims about the connection between vaccination and autism. Click on the image to go to the site.

Tom Meggison at Osocio comments:

It’s a simple, brutal and effective “viral” (no pun intended) to underscore the message that real people are dying as a result of illnesses that they could have been immunized against.

The site makes it clear that they don’t really hold Ms. McCarthy personally accountable for all of the deaths, but notes “as the unofficial spokesperson for the United States anti-vaccination movement she may be indirectly responsible for at least some of these illnesses and deaths and even one vaccine preventable illness or vaccine preventable death is too many.”

Belief is not evidence, and the link between autism and vaccines is in the same category as “theories” about chemical contrails and therapeutic touch as valid nursing practice. If there was ever a stronger case for evidence-based practice, I don’t know where it is.

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A Journal Article A Week (28.01.11): “Emergency nurses’ provision of spiritual care”

Rob Fraser at Nursing Ideas has an excellent project:

Think you have made all your news years resolutions? Think again. This year one of my goals is to keep up with more nursing research issues and trends, if I had an area of practice I would stick with that. To make this happen I am trying to read at least 1 journal article a week, the follow up to that is to share that with others. This can be done in different ways, Twitter, blogging, or even emailing it to people I think might be interested.

My goal is to blog one day a week with an update on the challenge and to share what I read. The hope is that I will do this one day of the week, and I’m going to try and choose a specific day to force myself to be consistent. However, if I really want follow through with this goal I am going to need some encouragement, but more importantly I am hoping to find partners in crime. If you are interested sign up below for what your goal for keeping up with research is and how you will share it. I’m going to post a list at the end of the month with whoever signs up. That way we can keep tabs on each other and possibly share around good articles. I will also be using Mendeley, to share the article in this group feel free to join.

I’ve joined and to kick things off, here’s mine:

APA citation: McBrien, B. (2010). Emergency nurses’ provision of spiritual care: a literature review. British Journal Of Nursing (Mark Allen Publishing), 19(12), 768-773. Retrieved from EBSCOhost.

The Skinny: Spirituality is a crucial part of nursing care, but too often in the emergency department setting, it’s ignored despite intense, intimate and frequent interactions with patients.

Money Quotes:

“However, the commentators conclude that spirituality is an important part of nursing care, but that it is seldom put into practice (Doyle, 1992; Oldnall, 1995). Benett (1997) believes that while nurses are educated and equipped to care physically, psychologically and socially for patients, spiritual care seems to be neglected. A number of reasons for this neglect have been identified, which include the absence of guidelines for the practice of spiritual care, the lack of an agreed definition of the term ‘spiritual’, and the fact that the spiritual dimension is not formally integrated within programmes of nursing education.”

“However . . . results revealed that nurses spent little time connecting with their patients. Nurses in Byrne and Heyman’s (1997) study describe a communication strategy of ‘popping in and out’ used to avoid spending lengthy periods of time spent with patients. The nurses also saw ‘getting patients through the department quickly’ as a more pressing issue than providing psychological support. Perhaps unsurprisingly, a lack of time was the reason indicated more than any other as the factor that influenced the respondents’ ability to connect with their patients and ultimately provide spiritual care.

Environmental factors such as reduced staffing levels or lack of privacy or quiet can have a negative effect on the provision of spiritual care (Ross, 1997). Nystrom et al (2003) observed that, within an emergency department, patients’ expectations of holistic and high-quality care from nurses were quickly reduced to expectations of perfunctory, physical interventions. Moreover, Nystrom et al (2003) suggested that participants refrained from complaining about the quality of care to protect their own integrity.

Pryce (1994) identifies some of the issues that hinder the application of spiritual care in the A&E department. The barriers she identifies are communication, fragmented care, task allocation, and nursing documentation. Indeed, the resultant effect of such barriers is that caring becomes ‘doing to’ rather than ‘caring for’. In a similar vein, Castledine (1993) believes that A&E nursing is faced with a dichotomy between technical competence and traditional supportive nursing. Furthermore, he identifies a holistic approach to the individual patient and family, collaborative decision-making and a more flexible humane environment as areas of A&E nursing in need of development.”

New Insight: Expert practice — meaning technological and clinical proficiency — in the emergency department should lead to greater skill in providing in spiritual care. In other words, how can you provide spiritual care when you can’t tell a sinus rhythm from a fib?

Why You Should Care: Providing spiritual care gives patients sense of well-being and spiritual connectedness as well as increasing professional satisfaction for nurses.

Next Week: “Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review.”

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Robots in Labour and Growing Medicinal Plants

For my American readers, and for Canadians who might have missed it, a couple of short CBC Radio One segments on some very innovative nurses.

Listen to them here.

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Irrefutable Evidence Dr. Weanus is Human

Dr. Weanus is old friends with Dr. Sendemtoemerg, the GP, having roomed with him as undergraduates at the University of Toronto. When Sendemtoemerg asks for his help in getting a patient admitted not having privileges himself (and therefore by-passing all that pesky business of being seen by Emergency) Weanus is ready, even eager to oblige. The patient, in fact, is not really that sick, having had influenza; she’s a touch dehydrated, and maybe needs an IV. More importantly to this narrative, she plays golf with Sendemtoemerg’s wife.

No problem, says Dr. Weanus, who believes his skill in cutting through the red taper and health care bureaucracy is legendary. Just send the poor dear to the Emerg, and I’ll admit her.

When Dr. Sendemtoemerg calls the ward clerk about this “arrangement,” the health care bureaucracy, i.e. me, is singularly not very impressed by this attempted end-run around the usual procedure, especially when the ED is already filled with admitted patients. Dr. Weanus knows this care plan is highly, um, irregular, if for the simple reason if every GP sent their patients to the ED “for admission” in this way we’d be sunk. Up the creek. Dead in the water. Pick your cliché. Our role in the larger functioning of the hospital is to prevent unnecessary admissions. We’re gatekeepers. Back-door admissions short-circuit the process.

“Absolutely not,” I decree. If this patient shows up at triage, she will go through the normal ED workup.

A little while later Dr. Weanus phones me. He is intensely irritated. He rants. He raves. He threatens. Why is this patient being seen by Emerg? Why is she not in a bed, awaiting my consultation? You are doing nothing for her! She is desperately ill! And so on. Standard Dr. Weanus, all shouty, sarcastic discourse.

I yawn. I know her labs are normal, and after a courtesy IV bolus, mostly a nod to Dr. Sendemtoemerg, she will go home.

Sometime after that I’m working on the staffing and I look up to see Weanus hovering over the charge nurse desk.

“I owe you an apology,” he says. His face is red. “My behaviour on the phone was inappropriate, and what I tried to do was wrong. I’m sorry.”

To say I am gobsmacked would be an understatement. One thing to note is I had become so inured to Weanus’s outbursts that I had to actually stop and think if he was that awful. (He was.)

“If the fool would persist in his folly,” said William Blake, “he would become wise.” Is it possible Weanus is learning? He’s reflecting on his behaviour. He’s trying to be a better person. Golly, he’s human after all.

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Credentials are Good. Credentialism is a Serious Illness.

In 2005 a baccalaureate degree became the standard for entry to registered nursing practice in Ontario, and there was a scramble in the years preceding to set up collaborative programs between the CAATs (colleges of applied arts and technology) which had previously administered the three-year diploma programs and the universities who would be granting the new four-year degrees. During this process, one new university program I am familiar with rather haughtily decreed that no mere BScN (or, God forbid, a diploma RN) would sully the ranks of its clinical instructors, most of whom taught part-time in the CAAT system while working full-time clinical positions. You see, BScNs couldn’t possibly teach clinical: they didn’t have the proper credentials, despite having years of experience that collectively ran into centuries. The university nursing program then proudly hired MScNs and Ph.Ds to fill the very large holes left by the departure of the BScNs.

An excellent plan — until the program administrators realized all their new hires had little or no actual front line, bedside clinical experience. I suppose they had read about it somewhere. However, it quickly became evident they were not competent — and were even dangerous — acting as clinical instructors.

Unqualified.

I was thinking of this story when I read Terri Schmitt’s excellent post on her blog about the push for not just graduate degree holders in nursing programs, but nurses with the degree in the somewhat esoteric field of nursing education:

I think nurses with graduate degrees in nursing education are critical to the education process.  However, I recently was made aware of one nursing program that openly told its faculty that they will not get promoted if they do not have a degree in nursing education. This proclamation was made after they had hired nurses with degrees in clinical areas like CNSs or NPs.  Those faculty members, some who are the most clinically competent that I have ever met, were basically told that they were second class citizens.  To me, and this is purely my observation, it had the feel of lateral violence.

I am not clear, exactly, what exactly a degree in nursing education means, and why nursing (alone of any profession, or indeed any academic discipline) needs a speciality to teach itself. Is there some previously unknown aspect in the pedagogy of nurses which uniquely requires this degree? I’m doubting it. A quick online search reveals MScNs in “Nursing Education” from such places as Jacksonville University and Drexel University in online courses. The cynical portion of my brain — admittedly a large part — thinks that “nursing education” programs are less an academic discipline than a niche marketing position, to differentiate themselves from a “generic” MScN. “Nursing Education” may well be a credential too far, but yet it seems some nurses have bought into it.

Unqualifed.

Nurses are very quick to add letters of all shapes and sizes after their names. We see not only degrees, but certifications and specialities, and even degrees not yet awarded. (My personal favourite is the MScN (Cand.), which I have observed lingering after some nurses’ names like a bad smell for years.) I have often puzzled over this obsession with credentials in nursing. It worries me, a little, that in the push and requirement for ever more exotic credentials, nursing will lose a great deal of diversity and perspective, especially in its leadership. Think that Florence Nightingale, who despite prodigious accomplishments, would not be qualified to teach at the university program I mentioned above. Hildegarde Peplau, who revolutionized nursing education and the nursing profession, would be fired because she didn’t hold a degree in “Nursing Education.”

Unqualified.

Credentials are good, as far as they go. They are a public declaration of qualifications. Credentialism, where degrees are unthinkingly required for their own sake in the vain hope of producing some undesirable uniformity, is the result of some very unflattering pathology in the nursing profession. Nurses and nursing still tend to undervalue their degrees and education, especially vis-à-vis physicians. Wielding degrees has become an exercise in compensation. Having the “speciality” of nursing education is just another way to do it. In this context, Terri Schmitt is probably on the money when she suggests some nurses use their superior education as a weapon.  Personally, I do get a little tetchy at the inherent, unspoken assumption the granting of any graduate degrees confers some magical superiority as a nurse. I don’t see see the point of knocking down one part of the profession to build up another. We all need to go forward together. All nurses have a valuable contribution to make to our profession, not just the ones with long strings of letters following their names.

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Thank you. Thank you. Thank You.

I just looked over at my odometer on the sidebar to the right and realized at some point yesterday, this blog clicked over 100,000 page views. I never would have guessed when I began writing here 16 months ago I would have such dedicated readers. I am grateful and humbled. Love and kisses to you all. Thank you.

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Some Days You Just Gotta Post Links Vol. 8

That sort of day. Cold and feeling like snow. Enjoy!

Carter: Worldwide, we only have 1,700 cases left, and we know where every single one is located. About 98 percent are in Sudan. But those last few cases are very difficult. If they were not so challenging, they would have been eradicated 15 years ago.

Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families during a loved one’s last hours of living. Clinical issues that commonly arise in the last hours of living include the management of feeding and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same whether the patient is at home or in a healthcare institution. However, death in an institution requires accommodations that may not be customary to assure privacy, cultural observances, and communication. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care.

Brazilian police are investigating the case of an elderly woman who was declared dead — only to wake up hours later inside a coffin in a funeral home.

The 88-year-old woman died two days after the incident and police in Minas Gerais state want to know if poor medical care and the misdiagnosis contributed to her death. [Or rather, undeath — ed.]

  • Grey’s Anatomy — created by Shonda Rhimes, ABC.
  • Despite a couple fleeting portrayals in which nurse characters displayed health knowledge, this popular hospital drama generally ignored nursing except for the occasional insult–and the fact that the show’s heroic physician characters regularly performed critical tasks that nurses do in real life.

  • Housecreated by David Shore, Fox.
  • This year included a few appearances from the snarky nurse Jeffrey, who appeared to have no real clinical role, but overall the show continued to present its nurses as anonymous physician lackeys and to have the brilliant Greg House and his physician team perform important nursing tasks.

    Damhof is the nurse navigator at the Willmar Regional Cancer Center.

    Barb Hoeft, director of the cancer center, describes her as “our go-to person.”

    “Every cancer patient needs a nurse navigator to talk to,” she said.

    Damhof does a little of everything: listening, advocating, troubleshooting, organizing appointments and referrals, and connecting patients and families with the resources they need

    • Somewhat related, if you want good news about the world’s oceans, don’t look here:

    Record warm ocean temperatures across much of Earth’s tropical oceans during the summer of 2010 created the second worst year globally for coral-killing bleaching episodes. The warm waters, fueled in part by the El Niño phenomena, caused the most coral bleaching since 1998, when 16 percent of the world’s reefs were killed off. “Clearly, we are on track for this to be the second worst (bleaching) on record,” NOAA coral expert Mark Eakin in an interview last month. “All we’re waiting on now is the body count.”

    Dr. Todd Hanna, emergency services medical director, and Kathy Racela, emergency department nurse manager, brainstormed, read medical literature and consulted colleagues to determine how to speed up triaging patients so that those with lesser complaints could receive care in exam areas in the front end of the department and save the hospital’s 28 emergency beds for more serious cases.

    At the busiest times, between noon and 11 p.m. seven days a week, the hospital has set up “rapid triage.” During these hours, a physician evaluates a patient within 30 minutes in an exam area near the check-in desk.

     

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