Portraits of Nurses at War

A small selection of photographs from the National Archives of Canada. Nurses have served with the Canadian military since Northwest Rebellion in 1885 and small contingents were sent to the South African War — the Boer War — at the turn of the last century. Nurses became an official part of the Royal Canadian Army Medical Corps in 1901, and have served in every conflict since.

Nursing sister, First Canadian Contigent, South African War

Nursing sister Ruby Gordon Peterkin. First World War. Note the boots — and heels!

.First World War, in front of a Casualty Clearing Station.

Unidentified Nursing Sister, First World War.

Nursing Sister Ruth Webster, North Africa, Second World War. Great photo. Colour gives this photo an unexpected immediacy. Note the utilitarian uniform, in contrast to the Boer War nurse above, the only concession to tradition being the headdress.

Same nurse. The Archive calls this one Nursing Sister Valerie Hora. Whatever her name — Valerie or Ruth — there is great strength of character in her face which the photographer has captured to an exactitude.

Nursing Sisters of No. 10 Canadian General Hospital, R.C.A.M.C., landing at Arromanches, France, 23 July 1944, about six weeks after D-Day. Eager and enthusiastic.

Canadian Nurses with Bob Hope.

Cpl. Bill Kay Strolls with Nursing Sister Dorothy Rapsey. North Africa? Second World War.

The price. Mass funeral of nurses after a German air raid. Note the nurses’ uniforms on top of the coffins.

Why Physicians Should Care about Amanda Trujillo

[This post appeared last week, in slightly modified form, at KevinMd.com. Nice to see it’s generating a huge response and vigorous debate there. TE.]

For the past month, the case of Amanda Trujillo has resonated deeply among nurses, triggering an avalanche of postings on Facebook, Twitter and in the nursing blogosphere. Trujillo is the Arizona nurse who was fired in April 2011 after providing education and making a hospice care consult request for an end-stage liver disease patient. This patient was slotted for pre-transplant evaluation and had poor understanding of the disease process and treatment options. Trujillo filled in the gaps for this patient. Trujillo then requested, at the patient’s own wish, a hospice team consult, documented her actions appropriately, and left a note (it was night shift) for the primary physician.

These actions — the education and the hospice team consult — drew the wrath of both the primary physician, who demanded her dismissal and her license, and also her nursing director, who told Trujillo she had “messed up all the doctors’ hard work and planning for the surgery.” The patient-requested hospice care consult was cancelled. Trujillo’s employer subsequently fired her, and reported her to the Arizona State Board of Nursing for exceeding nursing scope of practice, though in fact, nurses previously had ordered a hospice care consult without consequence. In short, many nurses believe Trujillo was fired for educating and advocating for her patient.

These are the bare bones of the story. (Further details can be found here and here.) The debate among nurses — sometimes heated — has common themes around the limits of nursing practice, the meaning of nursing advocacy, and how nurses in trouble are left high and dry by the professional organizations that purport to represent them. Well and good. But why should physicians care?

Before I answer that question, let me tell you about my own practice as a nurse in a busy Toronto Emergency department. I work shoulder-to-shoulder with some of the best physicians I have ever known. Our goal is give excellent care and treatment to every patient we see. In order to do this job well and effectively, I need some tools — like the freedom to educate and advocate for my patients — and recognition that my judgement and accountabilities as a nurse are quite separate, if related, to those of physicians.

More importantly, I need the confidence to know I can engage in collaborative practice — and this in not just a one-way street, by the way — with my physician Emergency department colleagues. This is not a theoretical proposition, incidentally. If I tell an ED physician, for example, that a patient’s needs are largely social, and I have arranged for social work, and if she discounts or minimizes my concerns, and cancels the referral, then the patient suffers in the end. If I tell her that in my nursing judgement, the patient is crashing, and she ignores me, the patient dies. Being an effective patient advocate and practising collaboratively with physicians (and patients too, I might add) is good patient care. Yet doing my job well is precisely the same sort of advocacy which got Amanda Trujillo fired and reported to the Arizona State Board of Nursing.

Physicians should be concerned about Amanda Trujillo for this reason: ultimately her case is about providing good patient care.  There are, of course, obvious serious issues about patient autonomy and the ability of hospitals and physicians to override patient decisions about their own care. Many physicians might sympathize with Trujillo’s arbitrary firing, or see in her case a reflection of their own professional concerns about the role of large health corporations in their day-to-day practice.

But for me, as a nurse, the issue boils down to whether the health care industry can tolerate highly educated, vocal, critically-thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with — and challenge, if necessary — physicians and established treatment plans. Or does the industry just want robots with limited analytical skills who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?

For me and most nurses, the answer is obvious. What about physicians?

Why Nurses are Furious about the Amanda Trujillo Case

The case of Amanda Trujillo has generated a great deal of passionate commentary across the nursing blogosphere. Trujillo, as you may well know, is the nurse who was fired by Banner Health Del E. Webb Medical Center for requesting multi-disciplinary hospice care case management consult for a pre-transplant patient with end-stage liver disease. The request angered the patient’s physician — not the transplant surgeon, incidentally, nor someone with any knowledge of transplant surgery — who complained to Trujillo’s manager. After her termination, the hospital subsequently reported her to the Arizona State Board of Nursing for exceeding her scope of practice. If the Board finds against Trujillo, she may well face the loss of her license or other sanctions; in the event, her nursing career would be finished. Superficially, at least, an open and shut case, or least this is how Banner Health would like to project the controversy. Scratch the surface a little and matters change considerably.

So why are nurses so furious? Part of it is the apparent coincidence of any number of other, seemingly random bits of information outside the direct narrative of Trujillo’s story. The fact that the Arizona State Board of Nursing chose to deem Trujillo’s attempt to defend herself publicly as “retaliatory behavior”  just as her story was becoming part of the general conversation, and then ordered a psychiatric evaluation is one of those seemingly random bits. This struck me particularly. Suspicious minds might see a pattern to punish Trujillo for speaking up by publicly labelling her mentally disturbed (and in health care, as any nurse will tell you, acquiring that label is doubly damning.) For myself, I will be content to note that throughout history calling people crazy is a traditional means of discrediting those challenging authority and marginalizing dissent.

And there are other random bits: that the Arizona Board of Nursing (for example) chose to inform Trujillo’s doctoral program of the ongoing investigation just last week — some ten months after the initial complaint. The apparent close linkages between various facets of the nursing “leadership” in Arizona, which I am told is known as the “Circle of Death” for woe to any nurse who crosses it.  The secrecy, the opacity of all the institutional players, from Banner Health to the Arizona Nurses Association. The sense of arbitrary and coercive behaviour from any of these. Separately, they don’t amount to much — but together? Suspicious minds, as I said, begin to see patterns.

But there are far more substantive issues the firing of Trujillo raises. Take, for example, the matter how and why Trujllo was fired. From Trujillo’s account, it was arbitrary and unjust. Trujillo acted, she says, in good faith; her intent was to help the patient make an informed choice about his treatment options; she had made the same request for similar cases previously without consequence or objection; there was no hospital policy positively forbidding nurses to make this request. The only difference, it appears, was the physician’s annoyance, that as Trujillo’s manager put it, Trujillo had “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

So there is this, a manager’s buckling under physician pressure, to do something about this turbulent nurse, a nurse who was trying to conscientiously to do her duty —-  which happened to conflict with the plans of the physician. But that is not even the really bad part. Let me put it in this way by citing an example that has weighty consequences for both nurse and patient. If nurse commits a serious medication error, best practice anywhere is for the hospital administration to do a root cause analysis. The purpose of this analysis is not to apportion blame, but to prevent the error from ever happening again. 

Once the root cause is determined, there might be changes to existing policies and procedures, and there might be education. Almost always, there is some sort of remediation of the nurse involved, because responsibility for a medication error is ultimately a shared responsibility from the nurse who administers the medication to the senior managers who are responsible for policies ensuring patient safety. For Trujillo, there was none of this — just security escorting her off the premises.

A reasoned, measured response to Trujillo’s actions, using root cause analysis, might suggest change and clarification of existing procedure for ordering case management consults. Instead, we have a nurse whose offence is so grievous that the hospital chose to fire her and then report her to the state Board of Nursing. To put it another way, even if Trujillo was completely in error in her interaction with this patient, and exceeded her scope of practice, what exact demonstrable harm was done to the patient?

I am puzzled why a clerical error — which I think is the worst possible cast one could put on Trujillo’s actions — merits termination and Board of Nursing discipline, while a serious medication error generally would not. It’s the gross inequity of outcomes which is so troublesome. Please note, in this context, nurses are generally fired and reported to regulatory bodies when there is concern they are a danger to the public.

So you have to ask yourself this simple question: even if you accept Trujillo exceeded her scope of practice, was firing her and then reporting her to the Board of Nursing proportionate to the supposed misdemeanour? Acting rashly, inequitably, without reason, and disproportionately, to my way of thinking anyway, is central to any definition of arbitrary and unjust behaviour.

We are also angry that Trujillo apparently was penalized for acting as her patient’s advocate and for attempting to ensure her patient could act with autonomy. This has serious implications for all nurses, because hobbling any nurse’s ability to act as advocate seriously jeopardizes patient care and safety. But first, the word “advocate” has been bandied about so much I want to inject a little clarity as to what exactly nurse-as-advocate means in the context of end-of-life care. This is what my own regulatory body, the College of Nurses of Ontario, says:

Nurses advocate for their clients and help implement their treatment and end-of-life care wishes. However, a client’s request to receive a treatment does not automatically bring with it the obligation for the nurse to provide the treatment.  A nurse is not obligated to implement a client’s treatment wish if it has been determined that the treatment will not benefit the client and is therefore not a part of the plan of care.

The College — no slouches in the matter of nursing ethics, by the way — goes on to tell us that that nurses act as advocates by ensuring patients have informed consent when implementing multidisciplinary care plans and by (says the College)

acting on behalf of the client to help clarify the plans for treatment when:

• the client’s condition has changed and it may be necessary to modify a previous decision;

• the nurse is concerned the client may not have been informed of all elements in the plan of treatment, including the provision or withholding of treatment;

• the nurse disagrees with the physician’s plan of treatment; and

• the client’s family disagrees with the client’s expressed treatment wishes

I think this is fairly standard nursing practice anywhere, and how all of us understand advocacy, whatever the stage of life. It is needful to point out the College phrases its language as nurses “must” not “may.” In other words, advocacy is not optional part of nursing practice. And what about patient autonomy? One of the four pillars of health care ethics, patient autonomy is the right of all patients to make informed decisions about their care and treatment, and necessarily implies outcomes matter most importantly for the patient, not the health care team. Nurse advocacy, it hardly needs to be said, is an important part of ensuring a patient can act an informed autonomous way.

So we have a situation where Trujillo was practising under universally accepted nursing standards, using the nursing process and nursing judgement, made a nursing assessment, educated her patient, in order that the patient could make an informed decision about his treatment options; in short, she acted to preserve her patient’s autonomy, and then was punished in the worst possible way for her attempts to be, well, a good nurse. Here’s her account, drawn from her lawyer’s representation to the Arizona Board of Nursing:

Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas. . .  Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions. . .

Ms. Trujillo and the patient reviewed the materials over the course of the night.  After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms.Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation.  She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

I am not seeing a lot of daylight between a world-respected professional regulatory body’s standards of nursing practice and Trujillo’s actions. I personally would do no different. Which brings us to the exact point of what disturbs and angers so many nurses: when hospitals run roughshod over a nurse’s professional and ethical judgement, when they refuse to acknowledge a nurse’s central ethical duty to sustain patient autonomy, there does not seem to be any point to acting as a professionals at all. Or maybe, that’s the real message hospital corporations want to send: that front line nurses aren’t really professionals, and larger questions of ethics and patient care are better left to higher beings — physicians, corporate managers and our nursing “leadership.”

This is why we are passionate about Amanda Trujillo. This is why we are so angry. The issues raised by the Trujillo case affect each of us, because this is how we practice nursing. By keeping patients — their wants, desires, needs, autonomy — front and centre.

Advocates for Amanda Trujillo — and I include myself in that number — have been criticized for jumping the gun, for not waiting for the other side of the story, for surely Banner Health and all the rest will have their speak. I concede the point. I accept I may be wrong. Not all facts are apparent, and some will never come out. (By the same token I am not clear what further details are needed to come out in order to form a reasonable conclusion about the situation. This isn’t the Pentagon Papers, or use a more modern reference, a WikiLeaks cache dump.) My sense of the situation, however, is that Amanda Trujillo’s position is far nearer the truth.

I say this not because of the documentation, or because I have spoken to Trujillo about her case (and five minutes on the phone with was enough to convince me of her utter veracity), or because she makes herself readily available to her supporters — she spoke with me for over an hour last evening despite an exhausting day, and was able to answer with clarity some very probing questions —  but because, sadly, her case follows the same pattern of abuse we have seen in other cases almost too numerous to count: arbitrary and vengeful behaviour from health care corporations, official investigations, attempts to discredit nurses and nursing and after a long time and huge financial and personal cost to nurse involved, vindication. And this is what frightens so many nurses: what happened to Trujillo and all the rest can easily happen to any of  us, and in the process, chip away at our collective professional integrity. So a lot of us in the nursing blogosphere and through social media are determined to hold the feet of Banner Health, the Arizona Board of Nursing and all the rest to the fire. The fact so many of us are so vehemently engaged in this issue speaks volumes about our determination to uphold the integrity of our beloved profession.

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.”

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?

__________

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.

Dying Alone, Continued

Thanks to commenter Pagan Chaplain (Twitter ~ web) for pointing out the No One Dies Alone program, where volunteers under nursing supervision support patients who would be otherwise alone at the end of life. The program was started by Sandra Clarke at Sacred Heart Medical Center in Eugene, Oregon. She cared for a patient in similar circumstances to what I described in my post and felt the same sort of distress:

One rainy night at Sacred Heart Medical Center, Eugene, Ore., I had a brief encounter with a man whose name I cannot recall, a man I shall never forget. He was one of my seven patients, near death and a DNR. During my initial rounds, he asked, barely audible, “Will you stay with me?” He was so frail, pale, old and tremulous. I said, “Sure as soon as I check my other patients.”

Vital signs, passing meds, chart checks, assessments and bathroom assistance for six other patients took up most of the next hour and a half. When I returned he was dead. I reasoned he was a DNR, no family, very old, end-stage multi-organ disease; now he was gone, and I felt awful. It was okay for him to die, it was his time—but not alone.

I looked around; scores of people were nearby providing state-of-the-art patient care. For this man, state-of-the-art should have been dignity and respect.

The last sentence is particularly striking — and true. It speaks to the core of what ought to be good nursing practice. In critical care areas we are sometimes entirely too focussed on the technical/technological aspects of care, when the reality is often much simpler. In the event, the wonder of it is not that such a program exists, but why it took so long for someone to come up with the idea, so obvious it seems in retrospect.

This is how it works:

A staff nurse generally initiates No One Dies Alone by calling pastoral care or, after 5 p.m., the nursing supervisor. The person who has signed up for that date is called. It is totally a volunteer program, and no minimum or maximum time has been set. The “compassionate companion” is provided with a parking pass and a meal ticket. We have a supply bag with a CD player, various CDs, a journal and a bible. We emphasize that any religious behavior will be initiated by the dying patient and not by the companion. Staff and the “compassionate companion” use an evaluation form in an ongoing effort to improve the program.

[. . .]

The reasons individual employees have volunteered are fascinating and as varied as their departments. Hospital carpenters, administrative heads, maintenance workers, nurses, secretaries, and kitchen workers have come forward. Some who come from large families cannot imagine someone being alone; others are alone themselves. One nurse from the cardiac cath lab has seen many die in spite of the high tech environment and care. He wanted to experience once again “why I became a nurse in the first place—to care for those who can no longer care for themselves.”

Other health care facilities operate similar programs, including a pilot project at the Royal Jubilee Hospital in Victoria. One can only hope the practice becomes universal.

Mary Hynes, of CBC Radio One’s Tapestry, broadcast an episode last year dealing with hope at the end of life, which included an interview with Sandra Clarke. It can be found here.

More on Meera Bai, Faith and Nursing

I realized after I wrote yesterday about Meera Bai and her work at Insite, the Vancouver safe drug injection site, that she has both a blog called Strong Hands and a Twitter feed — @senoritabai. When I spoke to her on Twitter last night, she pointed me to an article she wrote describing her experiences at Insite, provocatively titled “Why I Help Addicts Shoot Up.” A couple of excerpts:

Something about seeing people at their lowest and most desperate, half-clothed from turning tricks for drugs while hating themselves for it, opens into a profound level of intimacy. I am blessed to enter the darkest place of people whose sins are far more public than those of the rest of us. Constant humiliation makes the people I work with especially vulnerable, and vulnerable in almost every way: to violence, to exploitation, to false hope and finally to despair. When allowed into these dark places, it is my privilege, and that of all InSite staff, to communicate worth and love instead of judgment and scorn.

The day nurse asks me to keep an eye out for a specific participant—a regular who comes in several times a day. She hadn’t been seen yet. Later that night, the woman finally comes in, and she’s beaming. “I went to see my daughter today! And I didn’t use all day! F—, soon I’m gonna get off this s—!” We break out in applause and cheers, celebrating her triumphs with her—as she mixes her drugs to take in a few minutes in our facility. Other participants in the room are excited as well; two of them come over to hug her.

Another regular later chats with me in the treatment room as I dress his abscess, trying not to cringe away from the overwhelming odour he emanates. “It would have been my anniversary with my wife today, if she hadn’t gone missing. We’ve both been down and out, but she took care of me out here. Now, I got nobody to talk to. This is the first human touch I’ve had today.” I look up, startled. I am wearing gloves, holding my breath, cleaning his sores with a 10-inch sterile Q-tip. Even this, my deficient attempt to heal, is taken as love by a man desperate for human connection. I am ashamed.

I finish dressing the wound, clean up, remove my gloves and give him a hug. I hop up on the treatment bench next to him and we sit together and talk for another 15 minutes: about life, love and faith. He says goodbye, and then asks for a referral to an exit program. I give it to him. He knows the referral is merely one point along our journey together, and that I will listen to his story whether he goes to the program or not. As a Christian, I know that his life is part of God’s real story of redemption. InSite is one of the few places where I get to hear it openly spoken, with trust, without judgment.

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

Often, participants at InSite are forced to sleep outside at night. Not having a warm, safe bed takes its toll on bodies, and special care is needed for feet. An InSite staff member chats with me behind the desk as he fills up a basin of warm, soapy water. Kneeling on the floor, he gently strips damp socks off the swollen foot of a participant and lowers it into the soothing water.

Washing feet here isn’t an oddity from a discomfiting Bible story, but a regular occurrence. Foot baths are healing—for body and soul. As I fill up another basin, I marvel at the timelessness of this act of community. The humility necessary for all involved in washing feet produces beautiful vulnerability and relationship, which, unsurprisingly, creates change.

But really, go read the whole thing. It’s worth it.

Defending Insite from a Faith Perspective

A nurse offers a defence of Insite, the safe drug injection clinic operating in Vancouver’s Downtown Eastside. What I find interesting is that contrary to expectations,  Meera Bai’s work at the clinic is based on a very personal, explicitly Christian ethic:

I think that we are all extended grace by God and that we are all loved by God and made in the image of God. When we talk to addicts and we spend time with them, we see them as human, just like ourselves, and see glimpses of God in them because they were made in God’s image. … We’re clearly called in the bible to spend time with the marginalized and to protect those who are struggling. Many of these people have gone through incredible abuse in their childhood and throughout their lives. God, for us, as Christians, he’s a place where we can go where we don’t have to be ashamed.

[SNIP]

I gave a talk at Ambrose University College [a private evangelical university], which is quite a big seminary in Calgary. It was a public lecture and they thought maybe 50 people would come, but 150 showed up. One of the people who came, he put up his hand and said, ‘I’m a donor for Ambrose and I was quite appalled that they were doing this talk. So I came here because I think this is wrong. But now I realize what Insite does and this is completely what Christ would be doing. If Jesus was here, he would be washing feet the same way.’

It’s refreshing, for me anyway, to see a forthright explanation of the relation of a Christian ethic to practice in a way that speaks to compassion and service. This is in contrast the cramped and blinkered view of many of my co-religionists, whom I suspect would expend much time finding biblical justification for stepping over drug addicts rather than facing up to the fact these are human beings in need.

Nurses (or other health care professionals, for that matter) don’t often speak publicly about the ways the life of the spirit informs and motivates their practice, though I suspect for many nurses faith plays an important role. The problem is, discussing the role faith plays in the provision of health care almost inevitably seems to come back to the debate around therapeutic abortion, which in turn has distorted and marginalized any real talk about the role of faith for both ourselves and our patients. I sometimes thinks this is the reason nurses are hesitant to discuss spirituality or the spiritual aspects of care — with or without organized religion — even when we, or more importantly, our patients need and want it.

Gone Gardening, and Theresa Brown Gets Bullied

Spring has finally made a tentative appearance, so I’m outside communing with nature today.

A couple of thoughts to consider: First, is there a connection between bullying in health care and this?

Also, check out the growing dust up between Theresa Brown (@TheresaBrown), who wrote in the New York Times yesterday decrying the culture of bullying in health care institutions, and the somewhat defensive, hand-wringing reactions of some prominent physician bloggers, whose principal objection seems to be nurses shouldn’t have the temerity to call out physicians who bully them. I’m guessing, incidentally, most nurses will agree with Brown on this.

The Nurse’s Social Media Advantage

Congratulations and multiple woots to Rob Fraser, who’s published his book, The Nurse’s Social Media Advantage. The publisher’s blurb:

Social media has reached into every profession – and nursing is no exception. Almost daily, new research and publishing methods emerge. This fast-paced, ever-changing way of disseminating information will continue to evolve, whether nurses participate or not. With the vital role that nursing plays in the health care community, nurses cannot afford to fall behind. Social media provides exciting possibilities for networking, creating content, finding and sharing information and collaborating to create a global nursing network.

These changes can be challenging, but STTI’s new book The Nurse’s Social Media Advantage: How Making Connections and Sharing Ideas Can Enhance Your Nursing Practice will provide you with the tools you need for success.

The book is available from Amazon here.

Rob mugging with his book. Pic from his personal blog.

You get the feeling Rob is going places. Anyway, well done.