The Insanity of It All

Warning: my semi-annual politicalish post. When I read this, I admit I gawped:

$26,659: Our 2011 Medical Expenses

 Yes, you read that right. And we had insurance coverage for everyone last year, including daughter, 16, and my son who is 23 years old. Let me break it down for you:

• Insurance Premiums……………..$14,179.04
• Prescription Costs…………………$ 7,198.00*
• Doctors Fees, etc…………………$ 2,068.49*
• Eye care……………………………..$ 404.28*
• Dental………………………………..$ 2,752.00**
• Mileage……………………………….$ 300.00

* Costs in excess of insurance coverage.
** No insurance coverage.

Our medical costs in 2010 were $18,636. The principal reason why our medical expenses in 2011 increased by such a large amount was because our insurance premiums increased from roughly $7,000 in 2010 to over$14,000 in 2011.

This same crappy, expensive health insurance will likely be cancelled because my wife’s former employer has filed Chapter 11 bankruptcy and has filed a motion with the bankruptcy court to cancel all medical benefits for retirees and their families. My wife is classified as a retiree because she became disabled as the result of her pancreatic cancer, and the surgical chemotherapy and radiation treatments she received in 2006, and was unable to return to work. The story of her disability is described in detail at this link. Fortunately she is covered by Medicare, but we will lose even this crappy insurance coverage for myself, my daughter and my son.

I have a rare autoimmune disorder that unfortunately was not properly diagnosed until after the time had passed for me to file a disability claim with Social Security. Thus I am not eligible for disability benefits or Medicare. New York has a program for younger children that my daughter for which my daughter might qualify.

Because the insurance exchanges required under the Affordable Care Act will not go into effect until 2014, it is unlikely that my son and I can find insurance until then, assuming that the Supreme Court doesn’t find the ACA unconstitutional.

Basically one large every two weeks for medical expenses. Can any American defender of the status quo tell me why this isn’t completely insane and morally bankrupt? Or any Canadian admirers of U.S. health care — I know you are out there — tell me why the American system is superior in the fair and equitable provision of health care?

Just askin’.

Watching Your Employees Die Gets You -1,000,000,000 Karma Points

This is pretty appalling. Actually no. It is un-freakin’-believable:

Last month, Julia’s daughter, Vianney, buried her mom, after the 67 year old woman died Sept. 8th at her desk, at Time Warner.

“She went to Time Warner and didn’t come home,” said Vianney.

What Vianney didn’t know, is that more could have been done, to save her mother’s life.

Garfield Hts. paramedics rush to the Time Warner Call Center off McCracken around 3 PM that day.

Meantime, as Nelson lay slumped at her desk, a fellow employee begins CPR but records confirm, when EMS arrives, the patient is not breathing and contrary to red cross training, CPR is no longer being performed.

So why did the employee stop CPR? well, we tracked her down. She wouldn’t go on camera, but what she told us on the phone is shocking.

The women tells us, and other employees confirm, that a supervisor ordered her to end her life saving efforts, and “get back on the phone and take care of customers.”

What’s worse, there was an Automatic External Defibrillator device close by, in a locked room, and the only person who had the key was out of the building. Time-Warner, the employer, stated they “responded appropriately to a medical emergency. Our company has procedures in place to respond to emergencies.” Evidently, at Time-Warner, “appropriate procedures” include standing by idly and watching people in cardiac arrest die and keeping AEDSs in locked rooms so no one can use them. But there is a silver lining. At least customer service was good.

Death to PowerPoint and Other Notions

Back again.Yeah, I’ve been away for a while, for reasons that have absolutely nothing to do with writing or blogging. However my unintentional sabbatical has had the benefit of leaving me refreshed and full of ideas and so maybe wasn’t such a bad thing after all. I mean, in the two years I have operated this blog, I’ve written something close to 700 (!) posts, so maybe a break was in order before my brain turned into cranial equivalent of this.

So what have I been doing? A little of this and a little of that, but mostly working at the administrative-type secondment I’ve been assigned to for the past few months. I’ve worked closely with a group of other nurses, which I have been thinking lately resemble the Seven Dwarves. Their names are Pouter, Shouter, Passive-Aggressive, Bashful, Grumpy, Beautiful, Grandma, and of course, we have a Princess as well. (There isn’t an Evil Queen, though I don’t exclude the possibility I may in fact be that person.) Beautiful and Grumpy I don’t see much, and in any case I like and get along with them. Ditto Bashful, Grandma, and Passive-Aggressive. Princess behaves, well, like a princess though she has children old enough to be in university. But she’s a likeable sort and always means well. Pouter is irritating me all to hell; she’s pouting because I, um, spoke harshly to her friend Shouter, who walks around rigidly and inflexibly, like an angry exclamation point.

Shouter is generally tiresome to deal with, to the point where everyone tends to avoid conversation with her — which of  further angers her and makes her even more rigid and inflexible. Also, I don’t exactly like her (though Lord knows I’ve tried) and the feeling is even more reciprocal on her part. Not very constructive, I know, but I’ve concluded that not every relationship needs to be “fixed” — and frankly, this one ain’t worth the time and effort.

All in all, the work is fascinating, but I will be very glad to finish. I am beginning to think I get along better with the cat than I do with most people.

***                     ***                  ***

What else? A few interviews for other, more managerial positions, which in the inimical manner of Acme Regional’s Human Resources Department, have evidently fallen into the Hell of Waiting for an Answer. “Oh,” they say, “we’ll contact you in a few weeks.” I am not sure what machinations HR needs to carry out to spit out an answer, but there it is.

***                     ***                  ***

Death by PowerPoint. I gave my very first PowerPoint presentation to an enthralled group of colleagues on the topic of sepsis, which my employer has discovered to be the worst threat to patient satisfaction metrics since inedible hospital food. (Seriously. One of the reasons given for beating down sepsis rates at Acme Regional is “to increase patient satisfaction.” And here I thought “Not Dying” was sufficient enough.)

This was my presentation, in thirty-three PowerPoint slides:

Sepsis is very bad and many people die from it. We at Acme Regional, in an effort to be accountable and responsive to patient concerns, are determined to crush sepsis like mice under a stampede of rhinoceroses. In history, sepsis was discovered by Louis Pasteur. He was French. Other French people include Charles de Gaulle and Victor Hugo. They died of something else. In conclusion, not all French people die of sepsis. Thank you.

It actually went very well, I didn’t hardly talk about coagulation cascades and endothelial function, and people were very impressed, etc., and asked pertinent questions at the end like they had paid attention. I was pleased. Having sat through approximately a billion PowerPoint presentations in my nursing career, I have come to the conclusion the key for effective presentations involve three simple rules:

1. Less is more.

2. Speak to the slides, not read the slides. (Your audience is literate, right?)

3. Avoid pathophysiology like Yersinia pestis.

Or else, you can can check this out for good measure.

Labour Day and the Toronto Sun: An Annotation

Public sector workers are lazy and overpaid parasites sucking at the taxpayer teat. Or something. Please remember to tell us this when we’re doing ACLS on your sorry ass.

Happy Labour Day.

Love,

TorontoEmerg

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.

The Placenta, The Nursing Student and the Teachable Moment

Johnson County Community College has fired back at the harsh criticism it has received  — including from this blog — for its expulsion of four nursing students, including Doyle Byrnes, the student who initiated the lawsuit against the school:

Johnson County Community College plans to vigorously defend the lawsuit brought by a student against the college. The lawsuit also asserts individual claims against the members of the college’s distinguished faculty and administrators.

“The entire college community is disappointed that the students have decided to abandon the academic appeals process and take their grievances to the court for resolution,” said Terry Calaway, JCCC president. “We regret that the students used such poor judgment to take such a unique educational opportunity that was presented in a private clinical setting and broadcast it on the Web. We teach our students to respect the confidentiality of patient care, which extends beyond the hospital room and includes situations when the nurse is not in the presence of the patient. The actions of the students showed not only poor judgment, but also lack of respect and a complete disregard for the ethical standards of the nursing profession.

[snip]

“We will not tolerate such insensitivity on the part of our nursing students. We also must protect the reputations of our business partners in health care. We provide students with real-life patient care opportunities, and we take our responsibilities very seriously. Please know their actions do not reflect the standards of our nursing program, which is renowned for the quality of its instruction and its graduates. Thankfully, the situation was brought to our attention by other students in the nursing program. We are grateful they recognized the inappropriateness of the other students’ actions and sought advice from their faculty, who took immediate action to ensure the posting was removed.

“We will do whatever we need to do to reassure the community that this behavior is not what we teach at JCCC. Because we cannot tolerate such unprofessional behavior in our students, we took what we believed to be appropriate action. The behaviors of the students were insensitive and disrespectful toward the mother and the human tissue involved. The fact that this story has so quickly gone viral is evidence itself of how damaging social media can be if not used appropriately.*

“The students who took the photos were not expelled from the college, as has been reported, but were temporarily dismissed from the nursing program. They are permitted to re-apply to continue their nursing studies in August 2011 and to graduate from the program in May 2012. In the meantime, they have been asked to participate in a project on medical ethics, which could turn this unfortunate incident into a teaching moment for the students. However, the student who filed the lawsuit is getting married out-of-state in August and therefore wants to complete her studies this spring. She is suing the college for immediate reinstatement so she can graduate in May 2011 according to her own schedule.” **

Yes, there are certainly teachable moments, but the college and the nursing program seem to have studiously avoided them:

1. We often talk about the need to acknowledge errors made and an ethical approach would demand acknowledgement of error, reflection and restoration. For example, if I commit an error adversely affecting a patient, best practice is not only to admit the mistake, and learn how to avoid it in the future,  but go to the patient to accept accountability and responsibility. I wonder if the director of nursing had any second thoughts about the punishment she doled out, and if she did, whether she considered ameliorating it. She might have avoided a lawsuit, and her nursing program going viral on the Net in the worst possible way.

Interestingly, from the published accounts, the students seem to have understood this before the school escalated the conflict out of control. Not so their instructors.

A corollary to this is the old maxim from public relations (which for this school have been disastrous): acknowledge mistakes, fix them and move on.

2. The College is now telling us after being expelled, the students would be permitted to “reapply” to the program in August 2011, and if accepted, would graduate a year late. Meanwhile, the school is requiring the students to attend some sort of “project on medical ethics.” Despite the clarification, the punishment is still high-handed and disproportionate. However, clearly the director of nursing felt there was some gross violation of ethics (even if the rest of us didn’t perceive it); Doyle Byrnes, for her part, was contrite and apologetic, and she pulled the photo off Facebook as soon as it became an issue.

Given these circumstances, measured consideration and a pragmatic, reflective approach might have suggested first meeting with the students to informally discuss the concerns about the photo, perhaps with an impartial facilitator, then working with them closely to develop a learning plan to meet the nursing school’s concerns, while keeping them in the program. That, I think, would have been true leadership. Instead, there is virtually no hope any of the students will ever complete the required ethics course, and it’s probably doubtful they would even want to return in any case. I wouldn’t blame them. So if the director’s original purpose was remediation of the situation, and rehabilitation of the students, it was a complete failure. It accomplished nothing, except some highly negative publicity. An alternative disputes resolutions process may have worked better.

Put another way, what’s the procedure at this school when a student makes a med error, when the harm is actual, not virtual, theoretical or imaginary?

3. Nerdy Nurse: “Opportunities like this should be used as ways to write policies and develop protocols to follow regarding healthcare and the growing involvement we are all having with social media, from nurses to doctors, to grandmas, and great aunts. Everyone is connected.”

Again, mission not accomplished. In the end, I’m curious what precisely the nursing school did accomplish in victimizing it students, besides trashing its own reputation and a lawsuit?

__________

*I guess that means we should all just shut up, like good nurses.

** A few random thoughts about this train wreck of a press release:

• it still isn’t evident to me precisely which ethical principles of the nursing profession were violated. To say there was a breach of a patient’s confidentiality or privacy is frankly a stretch.

• a placenta, post-partum, is a discarded by the body because it is no longer needed, having fulfilled its function. To fetishize it by assigning it great intrinsic value in of itself  — how can you diss a placenta? — strikes me as bizarre (to say the least).

• calling the expulsion a “temporary dismissal” is pure spin. When you must reapply to be re-admitted to a program, you’re expelled.

• I have seen photos in nursing textbooks which were clearly more exploitative.

• the school’s real difficulty, it seems, was that the student posted the photo on Facebook, and Facebook, as we all know, ipso facto, is evil.

• related to the above is that it seems there was no clear policy on the use of social media by students.

• related to the above it’s pretty evident the school’s administration has no accurate knowledge of the nature of social media.

• and again, the school and its nursing program are behaving like the nurses we all hope we aren’t: vindictive, arbitrary, authoritarian, backbiting  and petty, i.e. the college’s lawyers now claim, for example, the reason for lawsuit is related to Byrnes’ desire for a May wedding! Excellent role modelling, that. And great messaging the nursing program is sending out too: that any nurse who advocates for herself (and by extension her profession) and challenges a perceived wrong deserves to be slapped down, hard. The point being, if the nursing school demands exceptional ethics and professionalism from its students (as they should), it should at least demonstrate how exceptional nurses behave: with compassion, insight, and clarity of thought.

How To Be Arbitrarily Kicked Out of Nursing School

In some states, public display of a placenta by a nurse is punishable by death

Want to get kicked out of nursing school? Display a placenta on Facebook.

The shorter version of this story tells of a director of nursing named Jeanne Walsh arbitrarily booting a student named Doyle Byrnes (right) from the from the nursing program at Johnson County Community College in Overland Park, Kansas only a few months short of graduation. Her heinous offence? She published on Facebook (with her instructor’s permission, mind you) a photograph of herself beside an anonymous placenta. In the letter of expulsion Walsh was brutal, yet undoubtedly fair — at least in her own mind. She wrote Byrnes: “Your demeanor and lack of professional behavior surrounding this event was considered a disruption to the learning environment and did not exemplify the professional behavior that we expect in the nursing program.”

I am mystified and not only by the Walsh’s evasive, accountability-shifting use of the passive voice. All I see here is an obviously excited, eager student with the “shiny shultz” side of the placenta showing in a tray.* Bad taste? Debatable. It’s certainly no worse than reality television. It’s not as though she’s swinging the thing around by the umbilical cord. Maybe instead of the contagious grin, she should be frowning at it slightly. Is there some gross violation of nurse-placenta confidentiality I’m missing?  What, did the placenta call to complain about its treatment?

Not Nurse Ratched had the best comment:

JCCC says it’s “a lesson hard learned.” Indeed, but not the one the school probably thinks it’s sending: the lesson is that nursing is filled with inexplicable decisions and finding out after the fact you did something Bad. This student can carry that lesson with her, but is it really one our nursing schools should be teaching? Can they not teach something more like “here’s an opportunity for education regarding healthcare and social media”?

Yep, indeedy, that pretty well sums up this school’s competency. No warning letter, no chance at remediation, just straight out the door. Nothing like grabbing the figurative axe for fixing a problem —  and incidentally demonstrating the nasty underbelly of nursing. Makes you wonder how this school reacts when a student actually does something serious.

So a few conclusions: first, Johnson County Community College’s nursing program is probably — well, let’s be kind and damn with faint praise: they do their very best, despite having no sense of proportionality — or humour. Second, higher degrees in nursing are evidently not guarantees of effective skills in either nursing education and administration. Third, we often talk about nurses eating their young. After seeing this story and hearing about others like it —  and it truly pains me to say this — I’m beginning to wonder if the source lies in nursing educators inculcating those old-fashioned nursing “values.” You know, the ones that say arbitrary and unjust behaviour, back-stabbing and treating nurses as expendable are acceptable. After all, isn’t this a classic example of how colleagues and superiors knee-cap young nurses and students?

__________

*Note to AtYourCervix: I was not sleeping all the time during my Obs/Gyne rotation.

English Only, or Else

Another exhibit in the Museum of Hospital Stupidity:

Dozens of Filipino hospital workers in California sued their employer Tuesday alleging they were the sole ethnic group targeted by a rule requiring them to speak only English.

The group of 52 nurses and medical staff filed a complaint accusing Delano Regional Medical Center of banning them from speaking Tagalog and other Filipino languages while letting other workers speak Spanish and Hindi.

The plaintiffs are seeking to join an August complaint filed by the U.S. Equal Employment Opportunity Commission in Kern County federal court over the hospital’s enforcement of a rule requiring workers to speak English.

Filipino workers said they were called to a special meeting in August 2006 where they were warned not to speak Tagalog and told surveillance cameras would be installed, if necessary, to monitor them. Since then, workers said they were told on a daily basis by fellow staffers to speak only English, even on breaks.

“I felt like people were always watching us,” said tearful 56-year-old Elnora Cayme, who worked for the hospital from 1980 to 2008. “Even when we spoke English … people would come and approach us and tell us, ‘English only.'”

And furthermore:

“Our co-workers, supervisors and any staff that doesn’t speak our dialect, they approach us once or twice a day along the hallways, nurse’s stations and even at break rooms, saying ’speak English’ even if we’re not talking, even if we haven’t opened our mouths,” Cayme said.

[snip]

Wilma Lamug, who is a plaintiff in the lawsuit added, “The president said whoever was caught speaking Filipino language will be suspended or terminated.”

I suspect this whole drama was the result some misguided initiative to “improve patient experience” or because of a patient complaint of dubious validity. Then the hospital got out the truncheon to enforce the rules — which speaks volumes, incidentally, about the quality of nursing work life at this hospital. And let’s be clear: it’s no use pretending these nurses and other health care workers weren’t targeted because they were perceived to be powerless in the hospital food chain. Do you doubt any physician would be subject to the same rule?

Leaving aside the demeaning and crude bullying tactics, co-worker harassment apparently enabled and encouraged by the hospital, dire threats from human resources, and the bizarre, Orwellesque promise to install security cameras to monitor spontaneous outbreaks of Tagalog, I had to ask myself: what were these guys smoking? Is there ever a good outcome when a hospital targets nurses by their ethnicity? Let’s tally this up. A lawsuit. International media exposure, for innovation of the worst kind.  Public approbation. A new reputation for racism. (I think this is a fair reading of the situation.) A strong message sent to the community that people of colour are not welcome on the premises. An equally powerful signal sent to health care professionals that whites only need apply — in an era where every HCP is gold. Conscientious nurses spreading the word through social medial about a thuggish employer. Snippy little blog posts from the likes of me.

Yep, looks like a all-round win to me, boys. Well done. The optics on this are fabulous.

More important, though is the effects on patients and quality of care. Achieving good patient outcomes is notoriously difficult when nurses practice in a poisoned work place. I’m guessing a hospital where staff are being deliberately pitted against each other because of nationality is not a very happy one.

In short: would you want to work there? Or be treated there as a patient?

Lose Weight by Breastfeeding!

Clever, but effective? A New York State public service announcement. [Via Osocio.]

My take: until the culture normalizes breastfeeding, even appealing to post-partum insecurities isn’t going to do much. And is highlighting pregnancy weight gain really the way to go?

What Do Nurses Do, Anyway?

If you’re a nurse, this is probably not going to come as a shock:

Students are in the dark about what a nursing career actually involves, according to a new poll to mark 100 years since the death of Florence Nightingale.

Many 18-year-olds are unaware that a nurse has the authority to give medicines to patients and can have prescribing powers.

The survey of 1,000 students from all academic backgrounds was carried out for the Florence Nightingale School of Nursing and Midwifery at King’s College London.

[snip]

Professor Anne Marie Rafferty, head of the school, said: “It is a worry that many students do not fully understand what a career as a nurse involves. We need to challenge and update the image of nursing to tell it as it is – one of the greatest and most rewarding professions providing one of the most precious services to society – compassionate, high-calibre care delivered by outstanding people.”

It’s a good question, and on the 100th anniversary of Nightingale’s death, probably one worthwhile asking ourselves: what exactly do we nurses do, anyway? What’s the point of nursing? Is it something that can be summarized in 25-words-or-less? How are we different in practice or in theory from the myriad of other health care professionals?

In short, what makes us unique? Or is our uniqueness a myth?