Archive for April, 2011

Do Nurses Have the Courage to Stop Bullies?

Hands up, nurse colleagues, if you recognize this story: bright young new grad lands dream job in sophisticated critical care unit by dint of hard work, persistence and perseverance, finds said unit is actually populated by orcs, trolls and toads. NurseXY provides the unpleasant details:

It was nice while it lasted, but the honeymoon is over. The true colors of my coworkers are starting to show through.

[SNIP --- but NurseXY's post continues with a heart-warming tale of nurses acting their very best. Go read the whole thing.]

I’m so very tired of hearing, [he goes on] “You have to be careful how you approach so and so about that.”

Why can’t I openly and clearly communicate my patient’s needs to those responsible for assisting me in caring for them? I am so tired of having to slink up to various people from docs to support staff like a helpless, hapless junior high damsel in distress to get what my patient needs. Too many egos to stroke. I demand respectfully request you grow the #@$) up.

And it’s only been 3 1/2 months!!!

I’ve written about the phenomenon of nurses behaving badly to their colleagues so often it’s tiresome. And sadly, I think, we’re all complicit in permitting bullying behaviour amongst ourselves, whether we are experienced nurses “breaking in” new staff, managers who avoid the issue, or tacitly permit it as a management technique (and this is far commoner than you might think), or educators who think abuse is the best way to train new nurses. It’s so ugly and so pervasive I sometimes despair for my profession.

RNnnnrGrl, after reading NurseXY’s post, vents on her blog at some length about the special hell of working with “seasoned nurses.” She’s on the mark, but maybe not in the way she thinks. While I don’t believe for a minute that bullying nurses make up more than a tiny fragment of our profession, how many times have we older nurses stood by silent while we let a bully tear into a nurse? When we passively let them stand unchallenged, it’s effectively the same as being bullies ourselves. So what to do? An excellent article at Medscape provides some practical responses to bullying:

Murray suggests that nurses should take a collaborative approach to bullying; nurses should “look out for each other,” and support victims of bullying during and following an episode, including reporting the incident. Victims are encouraged to document incidents of bullying, including date, time, site of occurrence, and witnesses.

Dellasega has this advice for nurses who witness an episode of bullying: “Intervene quickly to prevent minor conflicts from escalating.” Often, she continues, “a misperception or false assumption triggers behavior that spins out of control.” Because bystanders usually outnumber bullies and victims, they can act together to alter the situation’s dynamic and avert a bullying incident. “You can intervene on behalf of a coworker who is being bullied by asking her to help you with a task in another location, speaking up on her behalf, or simply standing beside her.” Dellasega also cautions nurses about participating in gossiping, which is also a form of bullying. [Emphasis mine]

I’ve highlighted the last bit because I think it speaks to something vitally important to the nursing profession, but often lacking: a sense of solidarity with your colleagues. Let’s say this plainly: either you stand with your colleagues, or you stand with the bullies. Afraid of retaliation or intimidation? You already have courage. You’re a nurse, right?

[Also, Sean Dent on the same.]

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Nurse Julie of Ward Three

“Julie Doran had been very happy in the busy, peaceful, atmosphere of the geriatric ward, caring for her aged patients and on the friendliest terms with the physician-in-charge, Hal Gardiner.

But everything changed for the worse when Annette Marsh came on in charge of the ward. Was is Julie’s fault — and if so, what ought she do about it?”

Harlequin Romance, first published in 1964, from the days when the principal social end of nursing, seemingly, was to catch a physician.

Will by-the-book Nurse March thwart the budding romance between Dr. Gardiner and Julie? And what about the dashing, controlling, Dr. Gavin Blake?

Also, note the nursing cape thrown carelessly over the shoulder. Clearly a nurse who will bend the rules!

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Union Works to Make Teddy Bears Safe Everywhere

Teddy bears win one in Ottawa (click the link and scroll to page 9), a fail for the nursing profession:

Thanks to the lobbying efforts of one Local Coordinator/Bargaining Unit President and her members, and the overwhelming support of the public, The Ottawa Hospital has backed down on its plan to forbid nursing staff from wearing “colourful” scrubs. As recently reported in a local newspaper, the hospital announced to staff a new dress code that would ban nurses from wearing scrubs or uniforms that are colourful or feature cartoon characters. Saying the change in policy was part of a push to make nurses “easier” for patients to identify, the hospital also announced nurses would have to wear white lab coats while away from their units, including while on breaks.

“The hospital said it wanted nurses to appear professional and recognizable, but as registered nurses, we pride ourselves on being considered professional,” said Local 83 Coordinator Frances Smith. “When we see a patient, we introduce ourselves and our conversation with that patient is the most important thing that happens, not if we’re wearing lab coats. Often, the most cheerful thing a patient sees in a day is our colourful scrubs.* Meanwhile, our members are overworked, with the hospital at over 100 per cent occupancy the majority of the time. [Emphasis mine]

I’m not sure this is a victory for nurses, though. I’ve said it before: dressing like you should work at Chuck E. Cheese franchise does little to help your cred, when explaining, say, to your patient’s wife why her husband has to go for emergency surgery for his AAA. More to the point: which other health care profession thinks it’s okay to wear teddy bear scrubs, outside of Paediatrics?

Answer: approximately none.

Just me thinking out loud, but it I firmly believe anything that tends to infantilize or trivialize our professional integrity is to be avoided at all costs. Even if it means chucking all of those teddy bear scrubs in the trash, or better yet, burning them in a hot fire of renunciation.

___________

*If  “colourful” scrubs are the best we have to offer as nurses, boy, are we in trouble.

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Sex, Vampires and Dentistry

Not a combination you would normally put together yourself, but I have to admit, it made me laugh.

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Favourite Poems XXXIV

Easter, 1916

I

I have met them at close of day
Coming with vivid faces
From counter or desk among grey
Eighteenth-century houses.
I have passed with a nod of the head
Or polite meaningless words,
Or have lingered awhile and said
Polite meaningless words,
And thought before I had done
Of a mocking tale or a gibe
To please a companion
Around the fire at the club,
Being certain that they and I
But lived where motley is worn:
All changed, changed utterly:
A terrible beauty is born.

II

That woman’s days were spent
In ignorant good will,
Her nights in argument
Until her voice grew shrill.
What voice more sweet than hers
When young and beautiful,
She rode to harriers?
This man had kept a school
And rode our winged horse.
This other his helper and friend
Was coming into his force;
He might have won fame in the end,
So sensitive his nature seemed,
So daring and sweet his thought.
This other man I had dreamed
A drunken, vain-glorious lout.
He had done most bitter wrong
To some who are near my heart,
Yet I number him in the song;
He, too, has resigned his part
In the casual comedy;
He, too, has been changed in his turn,
Transformed utterly:
A terrible beauty is born.

III

Hearts with one purpose alone
Through summer and winter, seem
Enchanted to a stone
To trouble the living stream.
The horse that comes from the road,
The rider, the birds that range
From cloud to tumbling cloud,
Minute by minute change.
A shadow of cloud on the stream
Changes minute by minute;
A horse-hoof slides on the brim;
And a horse plashes within it
Where long-legged moor-hens dive
And hens to moor-cocks call.
Minute by minute they live:
The stone’s in the midst of all.

IV

Too long a sacrifice
Can make a stone of the heart.
O when may it suffice?
That is heaven’s part, our part
To murmur name upon name,
As a mother names her child
When sleep at last has come
On limbs that had run wild.
What is it but nightfall?
No, no, not night but death.
Was it needless death after all?
For England may keep faith
For all that is done and said.
We know their dream; enough
To know they dreamed and are dead.
And what if excess of love
Bewildered them till they died?
I write it out in a verse –
MacDonagh and MacBride
And Connolly and Pearse
Now and in time to be,
Wherever green is worn,
Are changed, changed utterly:
A terrible beauty is born.

— W. B. Yeats

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In Case You were Wondering

I saw the respirologist and the Something is not the Big Bad Something, or even a life-threatening Something, but nevertheless a Something which will require further investigations. So breathing is possible again, so to speak.

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Thrilled to Death

The ride of your life in the form of euthanasia roller coaster. A thought-experiment where art, pop culture and end-of-life issues meet. I know some people who would be totally down with its realization.

According to the prospectus:

“Euthanasia Coaster” is a hypothetical euthanasia machine in the form of a roller coaster engineered to humanely – with elegance and euphoria – take the life of a human being. Riding the coaster’s track, the rider is subjected to a series of intensive motion elements that induce various unique experiences: from euphoria to thrill, and from tunnel vision to loss of consciousness, and, eventually, death. Thanks to the marriage of the advanced cross-disciplinary research in aeronautics/space medicine, mechanical engineering, material technologies and, of course, gravity, the fatal journey is made pleasing, elegant and meaningful. Celebrating the limits of the human body, this ‘kinetic sculpture’ is in fact the ultimate roller coaster: John Allen, former president of the famed Philadelphia Toboggan Company, once said that “the ultimate roller coaster is built when you send out twenty-four people and they all come back dead. This could be done, you know.”

[Via The Galloping Beaver.]

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Clinical Days: A Short History

Some random reflections on my clinical progress as a nursing student. 1990s.

First rotation: Medicine. A “heavy” floor. Mostly strokes, CHFers, Unstable Anginas. It was here I decided I did not want ever to work on a med-surg floor. The distress and despair among the nurses was palpable. Lots of encrusted, bitter old nurses, and equally nasty physicians engaged in a kind of ritual war of attrition; it reminded me of my parents’ soured marriage. Here I witnessed a physician publicly denounce a nurse* for holding an antibiotic causing an allergic reaction, her passive-aggressive response, and the utterly disheartening silence of her colleagues. And also: RN collecting a urine cultures by wringing out an adult brief; another RN packing a wound with her bare fingers; an RPN “punishing” a stroke patient by leaving him sitting in a stool-filled adult brief. His crime? Failing to use the call bell to call her for the bedpan. It’s a wonder I didn’t run away screaming.

Rotten unit filled with the worst representatives of the nursing profession. Happily is now closed.

Second rotation: Surgery. No specific memories, except for a shave prep of a vast inguinal hernia the size of a very large cantaloupe. Also the hallway was carpeted. On a surgical floor! Think various dripping body fluids. (When the carpet was finally taken up years later, it had to be treated as bio-hazardous waste.) Lots of suture and staple removal. Post-op baths. Sterile fields and aseptic technique.

Third rotation: Medicine. Here I got into trouble. I failed to document the necrosis on a right great toe. (No other nurse had either, though clearly it didn’t happen overnight.) Big fuss, got written up, warned and made to write a long essay to expiate my sins. Altogether a lot of to-do over what I would now consider a fairly minor documentation error. The reason for the fuss? The attending physician noticed the lack of documentation, and suitable scapegoat was needed. Actually some good lessons learned. One, take responsibility for your own documentation, and by extension your own practice, and never mind what everyone else is doing. Second, nurses eat their young if given the chance.

Fourth Rotation: Paediatrics. Superb instructor, but was known for failing one student every rotation. We all breathed again when the unlucky student departed the second week.

Fifth rotation: Psychiatry. Good instructor. I was told, rather disturbingly, I would make an excellent psych nurse. Long pointless conversations with non-disclosing schizophrenics and BDs. Otherwise, zzzzzzzzz. . . .

Sixth rotation: Surgery. Urology floor. TURPs, CBIs. Placed my first foley catheter and learned how to calculate true urine, a skill which in my ED career I have never actually used. This rotation was in the middle of some Harris government health care cuts. “Why would you ever want to be a nurse?” More than one staff member asked me. I was beginning to wonder.

Seventh Rotation: Surgery again, different floor. Rigid, unhappy nurses. The surgeons here deemed the nurses too stupid to find extremity pulses and decreed with the acquiescence of the manager  all pulses — even bounding radials! — had to be verified using a doppler. No one thought this demeaning. Nurses lived in fear of her, and the surgeons. Not a happy floor, and was very glad to finish.

Eighth rotation: Labour and Delivery/Post-partum. Great instructor. Lots of breast cupping, boggy fundi and lochia rubra. (Too much, if you ask me. Sorry, AtYourCervix.) Learned the archaic langauge of childbirth. GPA. Primip. EDC. Apgar. Presentation. Pre-eclampsia. Pit drips. The placenta freezer — the hospital sold them off to cosmetic companies. More than one mother utterly disgusted with the idea of breastfeeding, one of them telling me, “They’re for my husband.” Helped to birth one baby.

Ninth Rotation: Medicine. Different hospital than the rest. Great instructor, tremendous advocate for nursing who taught me, I think, about the potentiality of nursing, not its limitations. Physicians were respectful, the nurses generally enormously competent and more importantly (for me) welcoming to students.

Pregrad, first half: Telemetry. Awful. My preceptor  had the blunted affect of a chronic oxycodone user. Flat, uninterested, incurious, dull. She later went into nursing informatics. She disliked me, and franklyI wasn’t much fond of her either. When I insisted on doing full assessments, including chest assessments, she told me it wasn’t necessary because “that’s what the doctors do.” Telemetry floor apparently only in name. The only time I ever was close to quitting. It was that bad.

Pregrad, second half: Emergency. Amazing preceptor. When I witnessed my first trauma, all the intense orchestrated confusion, I confessed to her I thought I would never learn how to do it. “Oh you will,” she said cheerfully. Also she taught me the trick of placing the body bag under the sheets for incoming VSAs.** Except for the time the patient arrived VSA but survived long enough to go to ICU — after we discreetly removed the body bag. I have never done it since.

So, a mixed bag, and for better or worse making me into the nurse I am today. I suppose I did learn something, if by osmotic process — the mechanics of nursing, anyway. How to give subcutaneous injections. How to change sheets with the patient still in them. How to make mitred corners while making beds. (A skill which never leaves you, and then finishing by tucking in the pillow cases just so, exposed edge facing away from the door.) One of the things that strikes me is that how much of my real clinical education was by reverse example, if only because the exemplars — the nurses on the units — were often so terrible. I learned how not to treat patients, how not to eat our young, how not to pack a wound, how not to deal with physicians. To say the gap between gold-standard or even just normal good practice, and actual practice was significant and large would be an understatement.

Another thing: how few are the positive memories, how very scarce were the good instructors, how the two or three great ones shone. Education ought to be for challenge and growth — until the dead hand of educators comes along! Yet I can honestly say the two or three great teachers I had influenced my present practice in ways I can’t begin to express.

I’m curious: was everyone else’s clinical experience as ambivalent as mine?

__________

*It still amazes me, even now, to see physicians speak to nurses in ways they wouldn’t speak to their mothers, spouses, daughters, patients, the girl behind the Tim Horton’s counter, grocery store clerks, bank tellers. . .

** See Glossary.

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Empathy

Empathy is the hallmark of every nurse’s practice. It’s the concious act of putting yourself in someone else’s shoes in order to validate the patient’s emotions and thoughts, and to gain insight into their condition. It’s the foundation of therapeutic communication — nurse-speak for talking with your patients in a way that furthers and helps their treatment. Or so we learned in nursing school, along with those other Nursing Virtues such as Active Listening and Compassion.  But in practical terms is being empathetic with every patient all the time possible?

I was thinking about this a couple of days ago working in the Resus Room. I had a 20-something patient who was a victim of ovarian cancer, and who presented to the ED with increased pain, nausea and vomiting. She was, frankly, a mess. She was dehydrated. Her port-a-cath had just become non-functional, probably blocked with a clot. She had poor veins, so blood draws and IV insertion was problematic. She had hoped the progress of the disease had been arrested by chemotherapy and radiation. Unfortunately the CT scan showed extensive metastases to the liver and abdominal wall: the cancer had spread beyond all hope of cure. She bore this news stoically, her mother weeping quietly by her bedside.

She had an ileostomy from a previous history of Crohn’s disease; the stoma was inflamed, the seal was poor, and the skin around the site excoriated from the constant leakage of liquid stool.We had to clean her and change her sheets frequently. It was very unpleasant, and the odour was overwhelming. (Nurses are supposed to maintain professional composure at all times — this is pretty well ingrained in all of us from Day One in school — but even the best of us will flinch in the face of certain body fluids.)  She bore all of this with calm dignity, and after we bathed her, replaced the stoma appliance, gave her clean linens and made her more comfortable, she thanked us and apologized profusely for the leaking ileostomy.

She was not a difficult patient, clinically speaking. She was, as we say, “lovely.” After we gave our best care, and sent the patient safely to the floor, my partner-of-the-day said to me, “That’s a patient I don’t mind taking care of.” She was talking about empathy, of course.

Which made me wonder: what makes it easier to empathize with some patients, and harder with others? It isn’t just a question of complexity or difficulty or bad smells. In general, I think, patients who are stoic or resigned, and show even the slightest glimmer of gratitude — in short, the most passive in receiving care from us — are the easiest to empathize with. This might just be human nature. Contrariwise, nurses sometimes will speak of  “difficult” patients — demanding, blaming, complaining, hostile, manipulative, dramatic, but also those who are strong self-advocates (and, really, how do you tell the difference from the previous?) — and these, to be sure, are often harder to empathize with: it’s hard to walk in the other guy’s shoes if that guy is yelling in your face, right?

Maybe.  But I always think, in the back of my mind, when confronted with the demanding, yelling, manipulative, et cetera patients that there’s a reason behind being “difficult” — and there is almost always a reason, whether we think it’s valid or not. I once watched a superb nurse in my workplace defuse the “difficult”, screaming family of an elderly patient who had visited the ED repeatedly, and who was facing a long wait to be seen by a physician. By drilling down, and yes, by showing empathy she ascertained the real issues: the family needed more home care to deal with her increasing debility and they were at a loss at where to start for nursing home placement. Two things, in fact, we could readily fix. The patient and family left happy and grateful that someone had taken the time to really listen to their concerns, and we avoided an unnecessary admission. How many of us would skip the empathy and go straight to slotting the patient as “difficult?”

Being empathetic to the “lovely” patient is easy. And sometimes, I think, a bit patronizing. More challenging for nurses, and perhaps more necessary and important is the “difficult” patient. Yet it’s here we tend to fail.

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Persistent Infiltrate R Lung

This is what the diagnosis said on the emergency facesheet, after I got my post-pneumonia chest film taken at work.

The atelectasis in the left lower lobe has resolved. The right, not so much. There’s a bit of fluff there, a dab of whatnot, a smudge, a blot, an unknowable Something or Other.  There is no good reason for this fragment of whatever. It’s enough, though, for a referral to a respirologist (my respirologist, in fact) for a bronchoscopy, which is where the good physician put a cable of fibre optics and tiny little collection instruments down my gaw to visualize the various tube and tubules in the lungs, and it is exactly as pleasant as I describe it.

I’m not scared, exactly. Foolishly or not I don’t know enough to be frightened. How can it be otherwise? It’s still ill-defined Thing. It could be nothing or it could be Hell. But suddenly, issues of vast import seem trivial. Federal election, who cares? Taxes return — next week, if I get to it.

Maybe I will have a little Moment later, with tissues.  But not right now.

Important: spouse, friends, cats, dogs, garden, family, writing. Today the rest can rot.

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On the other hand, I was able to help a close friend successfully navigate a particular dangerous place in his health in relation to the health care system today.  Which leads me to a Profound, Trite, Reflection, that bad things tend to happen to people without cause or justice, but we each author what good things can happen to others.

And no, I’m not Pollyanna.

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