Archive for March, 2012

Best Laid Plans of Mice and Bloggers

Here I was planning to post on multitude of topics, including some stuff on breastfeeding, restraints, the duty to care, more twists and turns in the Amanda Trujillo case, the usual CVSaturday poem and Friday night short film, and I evenhad a wicked April Fools’ joke to launch on Sunday.

Life gets in the way. In in this case it is a family medical emergency which is going to be consuming my time over the next few days. There there won’t be any new posts until Monday at the very earliest, and maybe not even then. I’ll see you next week.

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Fat Nurses Need Not Apply

A Texas hospital has declared war on the scourge of obese nurses:

A Victoria [Texas]  hospital already embroiled in a discrimination lawsuit filed by doctors of Indian descent has instituted a highly unusual hiring policy: It bans job applicants from employment for being too overweight. 

The Citizens Medical Center policy, instituted a little more than a year ago, requires potential employees to have a body mass index of less than 35 — which is 210 pounds for someone who is 5-foot-5, and 245 pounds for someone who is 5-foot-10. It states that an employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional,” including an appearance “free from distraction” for hospital patients.

“The majority of our patients are over 65, and they have expectations that cannot be ignored in terms of personal appearance,” hospital chief executive David Brown said in an interview. “We have the ability as an employer to characterize our process and to have a policy that says what’s best for our business and for our patients.”

It all sounds so, well, high-schoolish, and I don’t think the CEO is seventeen, though he’s acting like it. I mean, can you get any more shallow? Since when does physical appearance have anything to do with competence or worth or dignity of any health care professional?

Or maybe David Brown doesn’t really believe nurses actually have skills — we just stand around as decoration, lookin’ pretty.

And fitting the  “representational image” of hospital employees to meet patient “expectations?” What the hell does that mean, anyway? If  patients expect this (and this is a pretty common “representation”)

A representational image of a nurse

then hiring practices should make sure all nurses are boobalicious? What if the patients want all-white nurses? Or all females? Or no Muslims?

The man is a bit of a dink, obviously. I can only imagine how valued overweight nurses employed by this hospital must feel.

The article goes on to note that this David Brown, CEO of Citizens Medical Center, has some issues. In 2007  he wrote memo about some foreign-born physicians in which he  stated: “I feel a sense of disgust but am more concerned with what this means to the future of the hospital as more of our Middle-Eastern-born physicians demand leadership roles and demand influence.”  He continued, “It will change the entire complexion of the hospital and create a level of fear among our employees.”

Needless to say, there is a discrimination lawsuit over that.

So let’s summarize what the leadership at Citizens Medical Center believes: scary scary fat nurses scaring patients. Scary scary dark-skinned physicians scaring employees and patients.

Clearly a place where I would want to work. Or be treated.

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Arizona is Where Educating Patients is Bad, Bad, Bad: An Amanda Trujillo Update

Just a few words about Amanda Trujillo.  Jennifer Olin at RNCentral.com has detailed at the latest twists and turns of her case. I won’t repeat everything, but I want to comment instead on the Arizona State Board of Nursing’s latest action. The BoN has added a further charge that Trujillo has misrepresented herself as “an end of life” specialist because she counselled and educated patients about end of life care, using the materials provided by her employer, Banner Health.

This is pretty outrageous, and I think, an abuse of process. Let me elaborate from my point of view as an Emergency department nurse. In the course of any shift I may give advice and education on:

  • wound care and dressing changes — but I am not a nurse specialist on wound care and dressings
  • casts and splints — but I am not a specialist in orthopaedic nursing
  • diet for cases of gastroenteritis — but I am not a dietitian
  • prescriptions — but I am not a pharmacist
  • preparation for diagnostic imaging — but I am not a radiography tech
  • advise first time pregnancies on the benefits of breastfeeding — but I am not a lactation nurse
  • head injury routine — but I am not a nurse specialist in neurology
  • treatment of fever in children — but I am not a paeds nurse

Now according to the Arizona State Board of Nursing, I am representing myself as a specialist in all of these areas, and probably a few score more that I haven’t listed. By the considered, professional judgement of the nursing leadership inhabiting the halls of the Arizona State Board of Nursing, I should just shut up, because I am clearly qualified to do squat.

The Arizona State Board of Nursing evidently believes nurses educating patients on anything is beyond their scope of practice. And by extension, nurses educating patients puts patients in danger.

Ridiculous?

Absolutely. And this is why this latest charge is a trumped-up nonsense. Nursing as a profession would cease to exist in Arizona if nurses had to meet the stringent requirements the BoN now apparently requires, if nurses need some sort of official certification as “specialist” before providing education of any sort. The “position” now put forward by the Board of Nursing is contradicts widely accepted nursing practice. Providing health teaching is the standard of care around the world. This is what nurses do. In my jurisdiction, you can be disciplined for not providing appropriate education.

Jennifer Olin puts it this way:

This just makes no sense. Trujillo may be interested in end-of-life issues, she admitted herself that she had provided such information to patients previous to the one involved in this incident with no objections from physicians or hospital management. In fact, that evening, she even cleared her plan of care with the clinical manager.

This is not claiming to be a certified specialist. We are nurses. We are expected to know quite a bit and, more importantly, how to find information for our clients and ourselves. The information Trujillo provided was pulled straight from the information banks of the hospital’s own computer system.

Exactly. This is what we know as nurses. We educate. To claim otherwise is to run against the experience and practice of millions of fully qualified and competent nurses. The Arizona Board of Nursing knows this too. They are nurses, after all. You can only conclude the Board is grasping at straws at this point, hoping to harass or intimidate Trujillo into submission.

The next step is an evidentiary hearing, for which the Board of Nursing has not yet set a date. As of next month it will be a year since this business started. The wheels of justice grind slowly, it’s said. Let’s just hope they grind as finely as advertised.

One more note: I spoke at length with Amanda yesterday, and she is very well and in good spirits. Her lawyer has asked her not to comment publicly further on her case, so I can’t relay what she told me. However, I will say the story grows more convoluted by the day and there is far more going on than can be publicly mentioned. So stay tuned!

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Scripting Nurses is Bad for Patient Care

This might be a new low in nursing management. Instead of actually providing caring, empathy and compassion, some hospitals would like nurses to provide a simulacrum of caring, empathy and compassion, believing patients are stupid enough not to tell the difference:

Nurses unions say an increasing number of hospitals nationwide are asking nurses to adhere to standard scripts when talking to patients, down to how often they use a patient’s name (at least three times per shift)

At several Massachusetts hospitals, nurses have been given laminated cards to hang around their necks with the words they should utter at the end of every visit: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’

These particular words, consultants say, are important because of research showing that patients are more satisfied with their care when they believe nurses made time for them. [Emphasis mine.]

This is called “scripting.”  It’s the newest shiny object for nurse managers. The underlying philosophy is that it doesn’t really matter if the nurse in reality establishes a therapeutic relationship, administers a medication properly and safely, completes a thorough and accurate assessment, or does all the myriad (and out-of-sight) procedures and processes necessary to ensure a successful and healing visit. All of that falls by the wayside: what’s most important and valuable is that the patient believes they got good care.

Of course, there is a fairly large gap between reality and belief. When I worked in the United States, my employer was exceedingly concerned with customer relations (I use the phrase advisedly), and regularly called nurses on the carpet for (allegedly) dissing patients. I personally was the recipient of a patient complaint in this regard: she believed I was missing in action for her entire visit. Fortunately I had charted extensively and nearly hourly because she was also receiving some high doses of narcotics and spent most of her visit sleeping. My care, in fact, and I will blow my own horn here, was exemplary. But you see the point. There is no such thing as the completely satisfied patient. It is a myth. The capacity for patients being satisfied on every aspect of their care is nearly infinite. Unfortunately, our capacity to make patients satisfied in all things is rather constrained. Patient care is complicated. It’s impossible to account for every contingency. Furthermore, patients sometimes equate nursing care to hotel room service. Sadly, we aren’t bellhops or waitresses. Trying to achieve patient satisfaction in each and every case  is a ultimately a losing game.

In any case, the value of scripting nurses, at least in the Emergency department setting, might be limited. One study indicates patient satisfaction scores remained constant pre-and-post introduction of scripts in an ED. This suggests to me, anyway, that scripting is just another in a long series of quick fixes for a problem which is actually hides the real elephant in the room: the link between nurse working conditions and job satisfaction, and patient mortality, morbidity and overall satisfaction. Nurse Keith at Digital Doorways excellently discusses this in blog post on the same subject. I won’t rehearse the argument at length, which basically boils down to “happy nurses make for happy patients.

So in the end, do you think treating nurses like idiots would increase or decrease job satisfaction? And how do you think that affects patient care?

[Update: corrections in formatting made. I sometimes forget WYSIWYG blogging isn't always WYSIWYG.]

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Favourite Poems L

Yes, the fiftieth edition of Favourite Poems. You might wonder why a blog about nurses and nursing (and some other stuff, but mostly nursing) does poetry. The answer is simple: because nursing is far more than all the mundane tasks we need to do to care for our patients. Poetry by its nature forces you to think in a different way, better understand the human condition, ourselves and, yes, our patients. If I had my druthers, I would have a poem read before every shift — though my colleagues might object.

Anyway, a few short comical poems by Ogden Nash.

 

Further Reflections on Parsley

Parsley
Is gharsley

*****          *****           *****

No Doctor’s Today, Thank You

They tell me that euphoria is the feeling of feeling wonderful,
well, today I feel euphorian,
Today I have the agility of a Greek god and the appetitite of a
Victorian.
Yes, today I may even go forth without my galoshes,
Today I am a swashbuckler, would anybody like me to buckle
any swashes?
This is my euphorian day,
I will ring welkins and before anybody answers I will run away.
I will tame me a caribou
And bedeck it with marabou.
I will pen me my memoirs.
Ah youth, youth! What euphorian days them was!
I wasn’t much of a hand for the boudoirs,
I was generally to be found where the food was.
Does anybody want any flotsam?
I’ve gotsam.
Does anybody want any jetsam?
I can getsam.
I can play chopsticks on the Wurlitzer,
I can speak Portuguese like a Berlitzer.
I can don or doff my shoes without tying or untying the laces because
I am wearing moccasins,
And I practically know the difference between serums and antitoccasins.
Kind people, don’t think me purse-proud, don’t set me down as
vainglorious,
I’m just a little euphorious.

*****          *****           *****

The Lama

The one-l lama, He’s a priest.
The two-l llama, He’s a beast.
And I will bet
A silk pajama T
here isn’t any Three-l lllama.*

*The author’s attention has been called to a type of conflagration known as a three-alarmer. Pooh.

— Ogden Nash

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Friday Night Flicks: Eye of the Storm

I know this short/music video by Lovett was criticized by some for being essentially plotless and shallow, but for me anyway, creating a  backstory to the nth detail indicates the creator thinks the audience has no imagination: trust me, there are plenty of hints and unanswered questions — and ambiguity — to make this worth watching. (Couch mode here.)

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Out of Sorts

Don’t know if it’s the crazy weather, but just feeling a little whacked today. Got up this morning, all burstin’ to write an epic post about the RNAO’s new best practice guidelines on restraints, wrote about three paragraphs and went bleh. Didn’t care as much as I thought. So maybe Sunday, if at all.

Other stuff: I made the Sunshine List — one of 79,000 —for the first time ever. For those out of province and out of country, the Sunshine List is the provincially-mandated disclosure of salaries over $100K for public and near-public employees. It makes for hours of entertaining reading. Really. Some of my colleagues made near $150K — and I thought I did a lot of overtime! ( I was a few thousand over.)

Also, some big changes coming soon to this blog. Are you excited yet?

Also: I know the great March heatwave is over, though its still 15C (60F) here as I write — about 8C (18F) above normal. More normally abnormally warm, if you know what I mean.  I went out a couple of days ago to take some pictures to document the tremendously early arrival of spring. Not great pics, but you get the idea something is strangely amiss. 

Daphne mezereum. Usually blooms here first or second week of April.

Maple blossoms. Maybe a month early, at least.

Maple blossoms en masse

Magnolia bud break. About a month early.

It would be foolish to attribute one weather event to climate change, the way anti-science types and assorted denialists think snowfall in Toronto in winter invalidates climate change science forever and for all time. However. . .

UPDATE: Minor syntactical fixes, because my hobbit-editor I bought ran away shouting some crazy talk about a magical ring.

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Nursing Makes Nurses Less Empathetic

Irony alert! The best way to decrease empathy in nurses, apparently, is to actually practice nursing. A new study of nursing students found that

as students gained more clinical exposure, they demonstrated a much greater decline in empathy scores over the year than did those with limited clinical experience during that year. This finding extended to students with previous work experiences in the clinical setting, who also evidenced declines in empathy of practical importance. . .

The study indicates the usual suspects in this decline of empathy: lack of time to empathetically interact with patients, lack of support, lack of role modelling, focus on the technical aspects of nursing and so on. It concludes:  “[U]ntil the art of nursing is recognized as a necessary criterion for successful completion of coursework and as important as passing an exam, students will likely continue to demonstrate behaviors that make them good technicians but not necessarily very good nurses.”

Ouch.

But I’m not very surprised. I was speaking to a friend the other day who is a clinical instructor for a certain university-based nursing program in Toronto. She told me of the open and enormous contempt the academic instructors at this university have for the clinical instructors (the majority of whom are bedside nurses as well) and by extension, for bedside nursing in general. (This isn’t the first time I have heard this, and I have experienced this myself when I was a clinical instructor.) It isn’t a large leap to suggest what we esteem in bedside nursing, i.e. empathy and compassion, are devalued in the same way, and that negative attitudes are passed on  to students.

The rot, it seems, begins early. I would be interested to know the experience of other clinical instructors, or new graduates. Or am I just talking through my hat?

 

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Observations and Assessments

NOTIONS TO SMALL FOR A BLOG POST, ALL IN ONE PLACE, A.K.A. THE PERIODIC LINK DUMP.

Further to my post “Sleepy Sleepy Nurse”: Sleep or Die. Really.

My jobRegistered Nurse.

We don’t know as much about infection control as we think we do. “Less than a quarter of the Clostridium difficile cases in a hospital could be traced to patients in the same ward, challenging a common assumption about how the infection spreads.” Medscape summary. Original article here.

And we’re not as smart at Triage as we think we are. Analyzing the records of 519 patients aged 65 years or older who were triaged using the Emergency Severity Index, from University Hospital Basel in Switzerland, found that 117 patients were undertriaged and 15 were overtriaged.” Anecdotally, I think this is true. My only quibble is why the small sample size? I mean, 519 patients is two days of volume in a busy ED, which means only a few poorly trained triage nurses could skew the results.

Nurses’ Presenteeism and Its Effects on Self-Reported Quality of Care and Costs. I read the article and went “Meh.” Rather evades the real issues around presenteeism, i.e. workplaces penalizing nurses for taking sick time.

Oh, dear.

On the menu: Pink Slime! I swear I will never, ever buy ground beef ever again.

And they didn’t live happily ever afterReal life Disney princesses, fallen. A photo exhibit by Dina Goldstein. My favourite: Cinderella knocking back shots in a bar on Hastings Street in Vancouver’s Downtown Eastside.

Younger than the Happy Meal. An important reminder from Fred Clark the supposedly “eternal” truths about abortion maintained by evangelical Christians are of much more recent vintage than you think.

Great music in the cause of crap content. Dissecting the cultural significance of country music. Quote:

The conservative movement has been cannibalizing conservative art for years now, to the point where I’d say country music is far from a victory of conservative cultural or artistic success and is instead a mirror image of what conservative politics have become: easy and unthinking. No depth, all surface. Superficial and insular. Maybe I’m wrong, but building an entire genre on the back of the idea that regurgitating the same sound on top of the same basic premise over and over again hardly strikes me as a triumph of cultural conservatism.

What language do deaf people think in?

Ayn Rand is the Karl Marx of the Right. Mostly because she tells people with incredible amounts of privilege they are the real victims in life’s lottery. Quote: “She offers them something that is crucial to every successful political movement: a sense of victimhood. She tells them that they are parasitised by the ungrateful poor and oppressed by intrusive, controlling governments.”

The Reformed Whores respond to Rush Limbaugh: “I’m a slut.” Hugely funny and right on the money.

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The Guy in the Next Bed

Code Blue on the floor: a lot like a Code Blue in the Emergency Department, except we have to run to the elevators, take a ponderously slow ride up to whatever floor they’re doing compressions, and then run some more down some endlessly long corridors till we find a room full of telemetry nurses looking out expectantly the doc and me and the ICU nurse (who flew down three fights and turned an ankle in the process.)

The patient, of course, is already dead. We just haven’t decided yet to make it official. This is one of health care’s best kept secrets: once a patient has gone VSA he is, for all intents and purposes, dead. Chances of bringing him back are minuscule — and yet not tiny enough to give up all hope of resuscitation. Once even I shook the hand of a woman leaving the hospital who coded on the ambulance gurney while I was triaging her the week before. So we continue. I pull out the drugs, and direct traffic, while the ICU nurse pushes epinephrine and atropine. The ICU Respiratory Therapist manages the airway. One of the tele nurses is assigned documentation, and there’s a short rotation of three nurses for chest compressions. The doc yells at one of them: harder! faster!

After the second round of drugs, it’s becoming clear the effort is futile, and we settle into the routine. Nurses doing compressions change every two minutes. Epi every three. When we briefly pause for the change, the monitor shows asystole. The ICU nurse and I chat. The RT cracks wise with the doc, and the tele nurses giggle at this, We banter back and forth. We joke. Another of health care’s best kept secrets: we chatter like budgerigars during codes. Then, through a crack in the privacy curtain, I see just this: two fidgeting hands clasped across a flannel covered belly.

Shit. There’s a patient in the next bed. I make frantic hand signals. I finally get everyone to shut up. A couple of minutes later, the doc pronounces. The room is silent. I can only imagine what he guy in the next bed is thinking.

And this isn’t the first time this has happened in my experience. I can remember a few occasions in the Emergency department where the guy in the next bed was a child who for various reasons couldn’t be moved.

So what do we do about the patient in the next bed, apart from shutting up?

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