Archive for January, 2012

Bedside Nursing as Menial and Demeaning

Ian Miller, blogging over at ImpactedNurse.com, notes a disturbing trend in Australia, one, I’m afraid, is becoming more common in North America. “These days,” he writes, “being a nurse is tough. Really tough.”

I look around and see many struggling at the bedside. I see the increasing perception that this is menial or bottom-of-the-professional-foodchain work.

I see more and more of this sort of feeling online.

[SNIP]

What our brightest and best nurses should be doing instead of creating a culture of escaping the bedside or doing time at the bedside is acknowledging that it is the nurse providing direct care to the patient or client that is the absolute most important domain of our increasingly diversifying profession.

Nurses do not really want to be business entrepreneurs, unless they have no other choice. They want to be nurses.

I would even argue that if you are not regularly within arms reach of your patient/client you are not nursing. And if you have not done this for a long time you are not really a nurse. You are something else. Strong stuff1 I know.

The bedside nurse should be re-valuing themselves not re-inventing themselves.

Miller’s solution is “8 in 8,” i.e. having non-bedside nurses work an 8 hour shift every 8 weeks at the bedside as a condition of their registration. This is an idea I like the more I think about it. However, it would be complicated to implement, not the least because of resistance from said non-bedside nurses — and can you see all those functionaries from nursing regulatory agencies or upper management pulling on scrubs and Crocs and tending to stool incontinence and urinary drainage bags?

Hmmm. Maybe not.

But Miller’s premise, that bedside nursing itself is demeaned and devalued to the point where many of us — including myself — are plotting our escape to greener pastures is sadly true. But why? The reasons for this are pretty simple. Despite years of education and rhetoric, nurses aren’t really permitted to practice to the full scope of our knowledge. We all have heard managers speak of their time at the bedside like it was a prison sentence. Television shows like Grey’s Anatomy tell us bedside nurses are stupid. We know that hospitals view nursing not as a valued added service, but as an expensive cost centre, and that Human Resources thinks of nurses as a “problem” to be managed, like the kitchen guys who make the salads, not as practising professionals.

To be clear, we menialize ourselves as well, when we view nursing as a job rather than a profession, or when we see nursing as a series of tasks to be completed before shift change, rather than a process requiring frequent periods of critical thinking.

It’s all pretty overwhelming, and though I will publicly stand up for the value of bedside nursing, and argue strenuously to its central importance in health care, there are times when even I have a little shadow of doubt.

So really I’m not very surprised if nurses of all ranks and positions view the bedside as menial and demeaning. If people around you all day tell you you’re worthless and menial, and if you view what you do as being more or less thankless and trivial, pretty soon you’re going to believe you are worthless and menial — and so is your professional practice.

I would like to tell you my own motives for escaping the bedside are pure, but when I seriously reflected about it, I realized some of my reasons for wanting to leave had much to do with decent hours and status. And something else:  the ability to act autonomously and effect change in a real way.

In other words, it’s all about power, and this explains why bedside nurses are so demeaned and devalued and want to escape.

Because we have none. Or think we do.

(I would argue front line nurses have far more power to shape their practice and workplace culture than they realize, but we all have been indoctrinated since the first day of nursing school never to question their place in the food chain and to always ask permission. And I’m not speaking about “making a difference in patient’s lives” — a phrase which has always struck me as infantile and meaningless. But this is a subject of a whole other post.)

 

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What the Amanda Trujillo Case Tells Me About Nurses Behaving Badly

Amanda Trujillo can take cold comfort that her situation is not unique. In the two years and odd months I have posted on this blog, I have written about six other cases where nurses (or nursing students) have been bullied and hounded:

Some of these incidents have been resolved. The near-farcical case of the over-exposed placenta, for example, which featured an hysterical nursing program administrator and a blistering court judgment, had a satisfactory outcome resulting in the vindication of the victim. Others, like the Nevada nurses, are in progress. And some, tragically, will never be concluded.

The common thread from all of these cases is they prominently feature nurses behaving badly. Not just any nurse, not your run-of-the-mill front line nurse, but nurses in management or leadership positions.

It’s worth repeating that it is not “Banner Health” or the “hospital” behaving badly. Saying “Banner Health fired Amanda Trujillo” is a  convenient way of avoiding the unpleasant truth that it is nurses making these horrifically bad decisions, at least in the initial stages. These are nurses acting in ways that are contrary to what most nurses understand as ethical and reasonable professional behaviour.

Amanda Trujillo’s nursing director, when confronted by an angry physician, thought it ethical and reasonable and professional to behave in such a way that any objective reading would perceive as bullying and intimidating. She decided to magnify this bullying behaviour by first firing Trujillo and then reporting her to the state board of nursing. The Arizona State Board of Nursing compounded the bullying . They deemed “retaliatory” counter-complaints Trujillo made against her managers without examining the context of the original complaint, and then by deciding to label her crazy by ordering a psychiatric evaluation.  And the Arizona Nurses Association, which apparently has links to senior management at Banner Health, finds itself unable to defend a victimized nurse, even though it supposedly “supports nurses professional responsibility to advocate on their own behalf just as they advocate on behalf of their patients.” More nurses behaving, not as nurses, but as school-yard louts.

In the world where I practice, and where I think the vast majority of nurses practice, this behaviour is despicable. It is outside the norms of professional ethics. I cannot conceive of any situation or circumstance where bullying and harassment can be justified in a nursing context.

Yet there it is. We can talk endlessly about power dynamics or hostile work environments or violence in the nursing profession, but in the end, it is wrong. We all know it.

I am fortunate in having an excellent nurse manager, and I personally and through social media know many, many nurse managers — leaders, really — who to my mind exemplify the nursing ideal: compassion, empathy, insight, critical thinking, ethical practice. Yet it is evident, that for some nurses, ascension into what we commonly think as leadership positions is seen as a licence to act like gaping assholes, and bully any underling nurse that comes in their path. Their behaviour is not nursing. It is the antithesis of everything that nursing stands for. It’s toxic, and it eats away at nursing like a carcinoma. We need to call out these nurses on their bad behaviour. It looks like in this case we are.

But it is to these nurses I want to address the thrust of this post. Leadership or management means that you must act with compassion, empathy, insight, critical thinking, ethically. Period. It does not excuse you from any standards of nursing practice. If you find you are in an irredeemable conflict between your perceived duties as manager or leader, and being a compassionate, empathetic, insightful, critically thinking, ethical nurse I strongly urge you right now to resign your registration. You are not a nurse. Stop pretending to be one.

Because we need real nurses.

Because, frankly, you are a drag on the profession.

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Voices For Amanda Trujillo

Each of them eloquently speaks to the heart of what we do as nurses — and why nurses find how Amanda Trujillo was fired and subsequently reported to the Arizona State Board of Nursing so troubling. (Via The Innovative Nurse.)

The first is from Andrew Lopez (Twitter: @nursefriendly.)

Kevin Ross is next (Twitter: @innovativenurse ~ Webpage: Innovative Nurse)

Michael Pergrim (Twitter: @CoachPerg)

Lastly Carol Gino. “The statement nurses eat their young — we’re not doing that. There’s a group of us who are going to stand with her. we’re not going to be powerless any more, because a defenceless defender is not good to anyone.”

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Favourite Poems XLV

An Old Man’s Winter Night

All out of doors looked darkly in at him
Through the thin frost, almost in separate stars,
That gathers on the pane in empty rooms.
What kept his eyes from giving back the gaze
Was the lamp tilted near them in his hand.
What kept him from remembering what it was
That brought him to that creaking room was age.
He stood with barrels round him—at a loss.
And having scared the cellar under him
In clomping there, he scared it once again
In clomping off;—and scared the outer night,
Which has its sounds, familiar, like the roar
Of trees and crack of branches, common things,
But nothing so like beating on a box.
A light he was to no one but himself
Where now he sat, concerned with he knew what,
A quiet light, and then not even that.
He consigned to the moon, such as she was,
So late-arising, to the broken moon
As better than the sun in any case
For such a charge, his snow upon the roof,
His icicles along the wall to keep;
And slept. The log that shifted with a jolt
Once in the stove, disturbed him and he shifted,
And eased his heavy breathing, but still slept.
One aged man—one man—can’t fill a house,
A farm, a countryside, or if he can,
It’s thus he does it of a winter night.

— Robert Frost  (1920)

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Friday Night Flicks: The Super List

A surprisingly creepy little film, if you have twelve minutes and thirty seconds to spare.

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A Small Rant from Your Friendly X-ray Tech

A note sent to me from my favourite MRT (Medical Radiation Technologist). A reminder too, that nurses aren’t the centre of the universe, even if we think we are.

Some thoughts from an MRT. . .

Now I know we aren’t perfect but I feel like a rant about portable examinations.

If a portable examination is requested it’s because the patient is too ill to come to the department, not because they are in the bed nearest the window and it’s a hassle to get them out of the room. Portable exams give less information than a department film so why chose inferior diagnostics?

So the patient is too sick to leave the floor might there be a need for a nurse to help the MRT with the patient? Just saying, just wondering. Now this help isn’t for the MRT’s benefit – though lifting and maneuvering people one handed is tricky – it’s for the patient.. Even if your patient is sitting bolt upright and square on do you think it’s a kindness to have them pulled forward by one arm as the heavy cassette is placed behind them? Because this is what the MRT has to do if the patient can’t lean forwards.

Oh and please don’t all run the minute the portable machine comes trundling down the corridor. It isn’t radioactive. And if you don’t have time to move 2 chairs, a commode, a walker,  and a couple of tables out of the room what makes you think the MRT does??

You know if you help with the exam then I’ll help put everything back in it’s place.

In Emerg, when you call the tech for a stat film then do acknowlede ge them when they arrive, and maybe even stay to help, (see above re too sick to go to the department.) If you don’t hang around then do answer the tech when they ask if the patient can be sat up for the film, or have any other questions about your patient.

Points well taken. Remember it’s about the patients, right? I’m pretty sure too other health care professionals have similar valid gripes about us. Ladies and gents, we need to pull up our socks.

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The Persecution of Amanda Trujillo

In the ugly, grey world of hospital balance sheets it’s almost a commonplace that physicians generate revenue while nurses represent a cost. Fancy procedures and sub-sub-specialties bring generous income streams, in terms of charging (and profiting) from the provision of a multitude of related services, such as nursing, while nursing itself, because it generates no revenue, is a burden to the bottom line.

It’s also commonplace, that in certain health care institutions, the power structure, the hierarchy of heath care, is so rigid (and fragile) that any challenges to that hierarchy — such as a nurse questioning the God-like omniscience of a surgeon — must be ruthlessly suppressed.

Amanda Trujillo

So when a nurse interferes with the revenue stream, dares to challenge the organizational power structure, hospital’s only logical recourse is to utterly destroy the nurse’s career. Take the case of Amanda Trujillo. Engaging in standard, no, gold standard nursing practice, following hospital procedures and using hospital materials, Trujillo correctly ascertained a patient facing end-stage liver disease did not understand a proposed transplant procedure or its consequences, and desired palliation instead. According to usual practice at this institution, and with the support and knowledge of her immediate manager, she requested a multi-disciplinary team consultation to create a care plan.

Amanda Trujillo tells the story herself:

My name is Amanda Trujillo. I’m a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care. Back in April of this year I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care). The patient also had no idea that they had a choice about whether they had to get the surgery or not or that there were other options. They asked about hospice and comfort care and I educated the patient within my nursing license and the nursing code of ethics. The patient requested a case management consult to visit with hospice to explore this option further in order to make a better decision for their course of care. I documented extensively for the doctor to read the next day and I also passed the info on to the next nurse taking over, emphasizing the importance of speaking with the doctor about the gross misunderstanding they had about the surgery. The doctor became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken. He was successful on all counts.

Let’s be clear about this and speak plainly: when the transplant surgeon primary physician found out about this course of events, mindful perhaps of lost fees, but heedless (it seems) of any apparent conflict of interest, and in fact, of any basic recognition of the principle of patient autonomy, he threw a temper tantrum, and demanded the job and licence of Nurse Trujillo.

The administrators at  Banner Del E. Webb Medical Center, heedless both of any apparent conflict of interest on the part of the surgeon primary physician, and in fact, of any basic recognition of the principle of patient autonomy, complied with this request. In the best tradition of blame-the-nurse, these faceless administrators — and I sincerely hope there are no nurses among them, because if there are, they are a complete disgrace to our profession — fired Amanda Trujillo. They then reported her to the Arizona State Board of Nursing, on the grounds that the request for the case management team somehow constituted a “medical” order, and therefore Trujillo exceeded her scope of practice. It’s important to realize these (hopefully-not-nurses) administrators designated this particular order as a “medical” order somewhat after the fact.

Very disturbing is the sheer maliciousness of the hospital administration at  Banner Del E. Webb Medical Center. Think about it for a minute. Even if you accept — and this is a  long stretch — that Trujillo exceeded her scope of practice, is the appropriate, measured response to ruin her practice, when the “error” was made in the best interest of the patient, in way that recognized and validated the patient’s right to autonomy?

Yet at some point an administrator decided the only appropriate, measured response was to utterly destroy the career of this nurse by screwing her over so royally she could never practice again.

(Nice job, Banner Del E. Webb Medical Center! I guess the best thing about this hospital you can say is that it it’s an awesomely bad, ugly, abusive place to work, if they would throw a nurse under the bus to appease a physician having a temper tantrum. It almost goes without saying that a place that is bad and ugly for nurses to work in doesn’t do much better for patient care. The case, in the event, pretty well makes that much clear.)

Amanda Trujillo’s hearing at the Arizona State Board of Nursing was supposed to have been yesterday. It was postponed for two months for a psychiatric evaluation because — wait for it — defending one’s self publicly on the Intertubes constitutes “retaliatory behaviour.” No, seriously. In the old Soviet Union, dissidents used to be labelled insane to discredit and marginalize them. Pretty well much the same obtains in modern nursing. Defy a physician, you get fired, you get investigated, and you get labelled crazy. And the Arizona State Board of Nursing facilitates the abuse, because as we all know, health care institutions never lie, and never have ulterior motives.

Nice.

So you want to be a nurse?

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Amanda Trujillo’s full story can be found here at Vern Dutton’s site.

Her Twitter feed is here.  Trujillo’s Twitter account seems to be deactivated this morning (26/01/12).  

Amanda’s new Twitter feed is here.

A Facebook page in her support is here.

Email the Executive Director of the Arizona State Board of Nursing, Joey Ridenour, RN, MN, FAAN: jridenour@azbn.gov

Complain to Banner Health here.

Nerdy Nurse’s perspective is here and here.

Please spread Amanda’s story as widely as possible. Every nurse is vulnerable to mistreatment.

UPDATE: 

Minor spelling corrections. Anyone know where I can purchase a hobbit to proofread?

Also:

Emergiblog:

Nurses not only eat their young, but God help you if the almighty Medical Establishment gets ticked off.
Nurses talk a great game. In the Halls of Academia and the Ivory Towers of Those Who Claim to Advance The Profession, it’s all “Nursing Is An Independent Profession” and we tirelessly “Fight For Our Right To Practice To The Full Extent Of Our Education And Training”.
Unless you’re down in the trenches doing patient care every day and someone gets angry that you have dared to advocate. And if that Someone is a Doctor, well, the bigwigs scatter to the four corners of the ring.
Musn’t create controversy.
Hell, they aren’t even standing on your side of the arena.

From Kim we also learn that the president of the Arizona Nurses Association (email the Executive Director, Robin Schaeffer: robin@aznurse.org) is the nursing director of Banner Del E. Webb Medical Center. Hence the deafening — and telling — silence of that organization.

And also Jennifer Olin. And NurseKeith.

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Kung Hei Fat Choi

Some Chinese New Year fun.

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Karma Sweet Karma

The latest instalment of Nurses Behaving Badly featured the night charge and the day charge (i.e. me) getting a status asthmaticus organized in Resus 1 a few minutes after shift change. It’s probably reasonable to wonder why the two Resus Room nurses weren’t attending (and attentive to) the situation, especially after we paged the physician and the RT in quick succession for a possible intubation, and especially since both of them were less than twenty feet from where we were working.

We thought at first they were getting report on the only other patient in Resus, but after 10 minutes or so we began to wonder how long it actually takes to give report on a stable, routine, admitted, pain-free NonSTEMI.

Meanwhile we got the patient on high-flow oxygen, assessed, drew blood, did an ECG, set up stacked Ventolin treatments, placed two large bore IVs, hooked the patient up to the cardiac monitor and generally got organized to tube the patient.

Turns out they were looking at a jewellery catalogue, drinking coffee, texting, socializing, what have you.

Grrrr. And when the night charge asked our two colleagues to cease and desist from shopping and tweeting and trading bon mots and actually do some, you know, nursing, we got the “whatever” look: face squinched up, hands up in the air, eyes rolled. The look that manages to convey a dishful of entitlement and irritation, with a light sauce of fuck you to complete.

Double grr.

By the time I gave my report, it was nearly an hour after shift change. But what goes around comes around. There is cosmic retribution and it is just.  That night Nurse Tweedledee and Nurse Tweedledum received, in addition to the now intubated status asthmaticus:

A cursing psychotic patient in four point restraints

A cursing drunken 20-year-old who managed to pee and puke all over herself all at once

A VSA*

Another VSA

A non-compliant insulin dependant diabetic in DKA 

And just before shift change, a fulminating CHFer, which required them to stay long after their shift was over.

In short, they had a craptacular night. The complaints, the bitterness, I am told, from the pair was tremendous. They needed to leave. They had child care issues. Husbands needed vehicles — and one of them was written up for being late. They were tired as no nurse in the history of the universe was tired. Why are we so afflicted? they moaned. What did we do to deserve this?

Karma, baby, karma.

The cosmic lesson being simple, work starts promptly on the hour. Not after fifteen or twenty minutes of “social” time. Be considerate of your colleagues. They’ve been working for twelve hours and want to go home. Many, many, bonus points if you come in ten minutes before to get report so the nurse you’re relieving can get out on time.

To say I had any sympathy for either of them would be a bald lie. Can you say schadenfreude?

 

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*VSA = Vital signs absent.

 

 

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Nurse, Interrupted

A pretty interesting video from Beth Boynton RN on what I call status interrupticus, the incessant and often needless interruptions nurses deal with when performing duties requiring critical thinking and judgement. It’s fairly well known, for example, at among nurses anyway, that many if not most med errors are attributable to nurses being distracted; I myself, during a code or trauma have sometimes reached for the wrong drug. In any case Beth nicely relates the problem to larger issues of healthy work places, meaningful nursing and professionalism. Worth a look.

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