How Nurses Practice

Working on a PowerPoint presentation, and did up this (yet to be formatted) slide:

Which column do you think represents the current state of nursing practice?

 

We Get No Respect

From Ian Miller at ImpactedNurse.com, a few thoughts on under-utilized and under-recognized senior nurses who are leaking out of the profession:

Nursing has few opportunities for promotion and recognition of senior expertise within the clinical setting. How often have you watched senior (and I’m talking about years of experience here) nurses move on to non-clinical management positions, or drift off into non-nursing jobs where their specialised skills are snapped up, or just stagnate on the floor (feeling little respect from the system) with nowhere to go and little exploration of the stuff they might teach.

What we are sadly lacking is a health system that gives the nursing ‘elders’ opportunity, support and recognition to pass on their profession, their experiences, their corporate knowledge and their craft to the next generations. This huge collective of nursing elders have so much to offer both the healthcare policy planning process in general and the future of nursing in particular.

As many of them are now approaching retirement the opportunity to pass on the craft will be lost forever. Skills that could be used to improve quality healthcare delivery, departmental operations and mentor-ship of other nurses. Believe me, those skills are out there in many of these people. They should be consulted not insulted.

Such a waste.

This seems to me about exactly right, and very nicely describes the  position — and present frustration —  of many nurses, including myself. The career path for the vast majority of nurses is pretty flat. The conventional nursing career path looks like this:

Graduation

35 years service on ward(s)

Retirement

Death

I am not exaggerating — not much anyway. Any movement, to be sure,  is usually in a lateral motion, e.g. from ED to ICU to PACU etc., but always as front line staff. Moving upwards almost always means a move away from your specialty. And that’s a waste too.

And there’s also this elephant in the room: would we be talking about things like wasted skills and staff retention if front line nurses were truly respected, and recognized as being the centre of what we do as a profession? Or to put it another way, if front line, bedside nursing was considered valuable in itself, would so many nurses be itching to get out?

Do Not Fold, Spindle or Mutilate the Nurse

An unpleasant, no, ugly and unfortunate situation at Victoria General Hospital is preventing a woman from seeing her son. From the National Post article:

A 73-year-old woman who travelled to Victoria from South Africa to care for her seriously ill son has been banned from Victoria General Hospital after she says she tapped a nurse on the head to get her attention.

Shirley Spence, originally from England, has been sitting in her rented apartment in Victoria since mid-May, barred from seeing her son, Gary Abbott, 52, who was found to have a brain bleed after falling ill.

Instead, every day her longtime partner, Andrew Regan, visits Abbott.

The couple say the situation is surreal and that they keep waiting for common sense and grace to prevail — but it never does. Abbott’s brothers and sisters in South Africa are incensed.

“I can’t believe I’m being treated like a criminal,” Spence said. She wrote an apologetic letter following the alleged incident, saying she was unaware of the no-touching policy, that no harm or aggression was intended, and that she will never touch staff in future. She ended the letter with a plea to see her son. But she was told it was not heartfelt.

[SNIP]

Despite what may seem like a disproportionate reprimand to the average observer, VIHA said it must support its staff on its own zero-tolerance policy concerning violence or abusive behaviour.

“Whether she tapped her or whacked her on the head, it’s unacceptable behaviour,” said VIHA spokeswoman Shannon Marshall. “The nurse’s story doesn’t vary from Mrs. Spence’s as I understand it.”

A couple of thoughts. First, at first glance, unyielding enforcement of a zero tolerance policy against abuse in these circumstances strikes one as not only defying common sense, but deliberately cruel. But then, there is this statement on the incident  from the Vancouver Island Health Authority (VIHA):

The Vancouver Island Health Authority (VIHA) has a zero tolerance policy toward violence of any kind – whether emotional, verbal, or physical – involving any member of our staff, physicians, patients, or visitors.

VIHA recognizes the current situation involving visits to a patient at Victoria General Hospital is complex and challenging – both for staff and the family involved.

Over the past week as this situation has unfolded, VIHA has been committed to the required risk assessment processes around violence in the workplace. In this specific case, a full and complete risk assessment was carried out. This process involved representation from BCNU, HSA, HEU, unit staff, VIHA (Unit Manager, Social Work, Occupational Health, Protection Services and VGH safety advisor). The risk assessment considered what occurred around the incident itself, relevant documents and facts involving family interactions prior to the incident, and the potential risk for future violence. The decision following the risk assessment was unanimous.

VIHA is very aware and concerned about the impact this incident has had on the staff member involved and other staff on the unit.

VIHA also recognizes the stress and concern the current situation is having on the family. Decisions to restrict visitation are not made lightly as we know the importance of family support and visitation in facilitating the recovery process for our patients.

VIHA is exploring ways to support the mother to visit with her son while he remains in hospital. In the short term, this visitation is unlikely to occur on the unit itself, but – as the patient’s condition allows – we are looking at ways to arrange visits in other areas of the hospital. VIHA will be working with the family very shortly to develop visitation arrangements. [Emphasis mine.]

The fact VIHA is doubling down in the face of hostile news reports suggests to me that there is more to the story than is superficially apparent. Note the decision to restrict visitation was unanimous among the risk assessment committee assembled to consider the matter. Perhaps the “head tap” was more than the gentle remonstrance of an elderly woman suggested in the newspaper article — try tapping your skull hard with your fingertips, and you’ll see what I mean — and I wonder too if there was a pattern of escalation.

At any rate it’s a tough balancing act. On one hand, hospitals have a clear legal and ethical duty to provide a safe work place for their employees and to protect them from violent and abusive behaviour. Zero tolerance policies are reflective of this duty. But throwing out family is not a great choice in any situation. Family members are generally considered integral to the health care team surrounding the patient. Note also VIHA is trying to find accommodation for the patients mother. I myself will not hesitate to have family removed if they interfering with patient care or if they are violent or threatening violence. My own rule-of-thumb is what I call the “Bank Teller Rule.” If the behaviour is inappropriate in a bank — and clearly, head-tapping your teller would be — out you go.

In case you are wondering, violence and abusive behaviour directed towards nurses is widespread. One study showed exactly how common violence is — and why, incidentally, I enthusiastically support zero tolerance policies:

Emergency Nurses
39.9 percent were threatened with assault
21.9 percent were physically assaulted

Medical Surgical Nurses
22.6 percent were threatened with assault
24.2 percent were physically assaulted

Psychiatry Nurses
20.3 percent were threatened with assault
43.3 percent were physically assaulted

(Source: Hesketh, K., S. M. Duncan, C. A. Estabroks, et al. 2003. Workplace violence in Alberta and British Columbia hospitals. Health Policy 63: 311–321.)

I think the study actually under-reports. Personally, I have been slapped countless times by demented and not-so-demented patients, I have been bitten to the point of bleeding, and once I was punched in the side of the head and knocked to the ground. This last was witnessed by police, and of course, no charges were laid. Again I repeat: why is there an expectation that nurses should tolerate behaviour from patients and families that is not tolerated anywhere else?

Did I sign up for any of this? Did any nurse?

A Nurse Contemplates Leaving the Profession [Updated]

Dinner last night with an old friend who toils in the mines of Labour and Delivery. She has worked there for four years. She told me of an incident not too long ago working the night shift, faced with a post-partum patient who was bleeding, hypotensive, and tachycardic, in short, showing all the signs of going into hypovolemic shock. She was running around, starting IV lines on flat veins and hanging blood products. Packed red cells. Platelets. Cryoprecipitate. And by-the-by, saline by the bucketful. She called for help from her colleagues. Apart from this patient and another who was walking the halls a few hours from delivery, it was a slow night.

Of course, you know the end to this story, don’t you?

No one came.

No one even popped their head in the doorway to ask, “Is everything okay?”

All of  them were at the nursing station, playing Draw Something on their phones, watching the season finale of Grey’s Anatomy, what have you. Too busy to help a drowning colleague with a shocky patient.

My friend went to her educator and her manager. They shrugged it off. No biggie, they said. Clearly my friend had things under control. “The patient lived, didn’t she?” they said. And then: “Maybe you need to improve your organizational skills to handle critically ill patients.”

This last to a 50-something woman who has been nursing 25-plus years, almost all of it in critical care settings.

For my friend, this incident may well be the last straw. She is definitely leaving L & D. Why would she want to stay? The workplace culture on this unit is awful. She feels alone and isolated when going into work. She can’t trust her colleagues. “Why,” she asks, “would anyone want to work there? There is no teamwork. No solidarity. Nurses backstab each other at the first opportunity.”

The only question remaining is whether my friend will leave nursing altogether and take her 25-plus years of experience with her, which included not only the knowledge to provide expert care to patients, but the potential to share that expertise in mentoring and nurturing new nurses. She’s uncertain what she would otherwise do, but leaning towards abandoning the profession which has shaped her adult life. She only needs an out — which she hasn’t found yet. She is that disgusted.

You might tell me that stories like this are unusual and not representative of nursing. Unfortunately, we all know better. So in the end, I don’t blame my friend for wanting to leave. I would do the same.

So what would be your response?

UPDATE: Some comments from Twitter:

@TweeterERNurse @TorontoEmerg I was “spoken to” about helping other nurses too much, as it increases MY pts time in the ER. I applied for another job.

@SqarerootofeviL sad but true.. seen my ma & aunt live it.- “No teamwork. No solidarity. Nurses backstab each other at the first opportunity.” @torontoemerg

@NorthernMurse @TorontoEmerg So how do we change this culture? What do I, as a student and soon new grad, do to improve the #NursingCulture?

@TweeterERNurse @NorthernMurse @TorontoEmerg Learn more than your manager about regulations. Google everything on the inservice boards. Become the expert.

The second to last tweet from @NorthernMurse is probably the relevant question, don’t you think?

Guest Post: How We Can Fix the Malaise in the Nursing Profession

by Amanda Trujillo

If the newer generations of nurses out there are more confused than ever about their roles in healthcare  —   they should be. I’m one of the newer generations of nurses and I — AM — CONFUSED. Seriously. Think about it. We are taught all of the idyllic, pretty things every good and prudent

Navy nurses attending to a patient, 1960s. (Photo credit: Wikipedia)

nurse should know and should do whilst caring for patients. The Nurses Code of Ethics is drilled into our heads during nursing school, nursing care plans are celebrated (by our professors of course), and we are championed as the “future” and “promise” of nursing. The beautiful glowing white walls of academia ushers us out of the proverbial nursing nest with a maternal pat on the head, a gentle push, and into the place were supposed to actually do all the stuff were taught and licensed to do, and be who they taught us to be.

You’ve all heard it, I’m sure. “Get out there and make a difference! Change the profession for the next generation! Be the example! Implement policy! Be advocates for your colleagues and your patients!” Ummmm. Yeah. Nurses should act as advocates for not just their patients but for their profession. That being said, let’s take a look at what threatens to unravel the foundational fabric of who we are as nurses and what we do that sets us apart from all other healthcare disciplines.

1.  Corporate Nursing.  ”We know what nursing is and what nurses do.”  However, the moment you walk into the doors of any hospital, the nurse — the persona, and everything else —  is redefined according to the wants and expectations and interests of the organization we work for. Nursing, as a discipline, as a science, is redefined. You are who your employer wants and expects you to be. Period. Your own nursing style or “way” of nursing? Leave it at the door, and step into the predefined mold thank you very much. Advanced education? Yeah, that’s great, but you aren’t actually supposed to use it. That MSN is supposed to look good after your name on the plaque that lists all the Masters prepared nurses on the unit you work within. A point of pride that all patients are supposed to gawk at and be impressed by when they walk into the entry way of the nursing unit. I tried using it; I tried to contribute—nope. We just want the letters from you, that’s all.

2. Teeny, tiny amount of autonomy. I mean, come on people. We still have to get orders to ambulate our patients two to three times daily after surgery, to get an incentive spirometer, to initiate pre and post-op teaching, and even to monitor ins and outs every four hours. Every state has a different nurse practice act, and there is no set regulation as to what nurses can and cannot do across the United States. Every state defines Nurses and their practice and what they can do differently. Take a group of 5 doctors—and chances are each one of them don’t even have a good understanding of what nurses are and what they do and their role. Interdisciplinary Models of Care are not the standard yet, so this inhibits a productive and working knowledge of what each provider does.

3. Disregard for Care Plans. This is a big one for me. I recently read a couple of articles that, for the most part, said care plans should just die and go by the wayside because they are useless.

4. A fractured profession. We have so many specialties that we still have failed to come together in a unified manner to advocate together for our profession and for the vital role we play in the lives of our patients, evidence based practice, theory development and application, and policy making. The result? Thousands of different visions from thousands of different nurses about what our profession “should be” and “should do.”

5. Silencing of our voices. We now have to choose between our own career survival, or own livelihoods, professional reputations, and paychecks—and speaking up in the best interests of our patients. Many a nurse has experienced this tragic conundrum, and the consequences are well documented if you log into your university libraries and do a good literature review on the topic. So, which will it be? Your pay check or your patient’s life? Well, now, that depends—can you like yourself when you go to sleep at night or when you wake up the next morning. The choice will be different for all of us.

6. Too many initiatives!!!!  There are so many initiatives out there that it truly is like ‘herding cats’ to get everyone on the same page about what needs to bedone to improve, advance, and grow our profession.

The American student nurse Miss Lydia Monroe of Ringold, Louisiana, in 1942. (Photo credit: Wikipedia)

What I feel needs to be done is simply this: get back to basics. All the initiatives are great. The pretty, flowery, shiny,  idealistic profession they propose is in theory—just that. It seems like every time we turn around there is another nursing initiative being introduced. In fact, there are so many, we all seem to have thrown up our stethoscopes  in exasperation while uttering “Whatever.” The RWJF, the NIH, AACN, the National League for Nursing, Johnson and Johnson, the Institute of Medicine and all the other organizations that produce the massive documents proposing their positions on where nursing should be by the year “such and such” need to set aside “Candyland” and get back to the drawing board.

How? Perform a learning assessment and care plan on the profession. TALK TO THE NURSES AT THE BEDSIDE—these are the stakeholders that have to carry out all the grandiose changes. ASK nurses what would motivate them to carry out change and what they need or want to learn to carry out the change. Perform a force field analysis to illustrate whether there is a greater push for or against change and where a balance can be achieved to promote success. What do nurses consider an incentive to participate in the change process? What is their currency?

Here is a good example of what happens when big organizations try to make even bigger changes sans discussion with their staff members, which is to say, their stakeholders. At one hospital I worked at the Transforming Care At The Bedside Initiative was being “enforced” as a means to improve patient satisfaction scores. I say the word “enforced” because we nurses weren’t asked about how we felt about it, we weren’t “completely” educated about what TCAB was, why we should be interested in it, or why we should participate in it. participation was an expectation and people were “assigned” to do parts of the initiative. No communication took place between management and staff about how they felt about the change process or the new “tests of change” they were being expected to participate in.  So, it was not a big surprise  to see my coworkers increasingly annoyed when they were being presented with “more steps” in their workday, or “more papers” to fill out or “scripts” taped to their computer monitors directing what they were to say to their patients. It was also not surprising to see that few or no staff members were attending the TCAB meetings to provide input and feedback.

Having gotten my Masters Degree I quickly realized what was missing was a well-planned approach to the change process. A crucial step within the change process is involving every person that could possibly be involved in that change: polling people, studying your stakeholders and what their motivations are, illustrating what is ‘in it for them’ should they take part. Failing to study all of your stakeholders and ask for feedback prior to initiating change is simply wasting a lot of time and yelling through a megaphone at an empty nursing station. I did some further research into the TCAB Initiative by immersing myself in the RWJF website for a couple of weeks.

After doing so, I discovered that our organization was not implementing TCAB as it was meant to be implemented. The organization was taking bits and pieces of the initiative and implementing them. The focus of the initiative — promoting happy nurses to promote happy satisfied patients — was not the managerial focus, as it should have been. It was strictly designed for patients, completely overstepping the spirit of the TCAB initiative as it was meant to be implemented. Lastly, the TCAB initiative was designed to be an interdisciplinary effort. The way it was being pushed at the organization I was at, the focus was just on nurses. I put together a white paper and power point and submitted them to my manager hoping it would help to get the project on track. I was promptly shut down with an annoyed response that my work looked plagiarized. (This is what an MSN on a nursing floor gets you)

So, managers, here are some lessons learned. If you want to make change on a large scale you must invest the time, no matter how long or how involved the effort, to study the people who have to carry out the work. Find out their goals, wishes, motivations, concerns, what makes them happy, angry,  and frustrated. Find out what their knowledge base is and what must be learned to carry out the major initiative. Ask for their input. Discover who your “downers” are, why they are resistant to change, and how can you get them on board. It’s called “buy in.”

Lastly, harvest your talent. Take a fresh look at who your voices and cheerleaders are on the unit and give them “room to bloom where they are planted.” This is how and where you become a transformational leader instead of a leader who suppresses the creativity and potential of your nursing staff. One note: if you are going to implement something huge like the RWJF TCAB Initiative, don’t just take pieces of it and throw together your own version and expect it to work.

(Photo credit: Wikipedia)

This, in my opinion, is what all of  the large nursing organizations who want to transform healthcare need to do. Round everybody up for a week-long conference, every stakeholder — not just administration and management figures or politicians either. The real people: the bedside nurses, pharmacists, lab workers, patients, doctors, PA’s, housekeepers and so on. Paint the closest picture you can get to a collective vision everyone seems to share. Then, figure out how to get there, one step at a time.

All the big goals are great.I love the visions of where the RWJF and the IOM and the AACN see our profession, healthcare, and nursing education headed. But the visions are a problem too.  There are too many ideas, initiatives, and too many people “other than bedside nurses” generating them. Our profession is fractured enough. It is not feasible, nor is it realistic, to expect every wonderful idea and vision to be carried to fruition when there is currently a longstanding lack of unity and disarray within nursing.

So, for the time being, let’s set aside the huge mountain of ideas and initiatives and take a deep breath. Now, start over with the A-B-C’s: Airway, Breathing, Circulation. Set the sights on resuscitating the profession of nursing first, before we attempt to heal the ailing healthcare system and the world. Take it back to the old school, and do the assessment first. Then, make a plan: implement it, evaluate it, and do it all over again until we get nursing back on track with a unified focus. Only THEN can we climb the mountains set in front of us by the RWJF or the IOM or the NIH. We cannot build castles without a strong foundation of earth below it.

By the way . . . Did anyone notice how often I used the word “initiative?”

__________
Amanda blogs at NurseInterupted. This is a slightly modified version of a  post which originally appeared on her blog.

Nursing Week Ain’t What It Used to Be

My Nurses Week joy was shattered last night when the son of a patient reamed me out for discussing the patient’s condition and treatment plan — wait for it — with the patient. He thought his father, who was a rather elderly but very independent and shrewd man who still lived in his own house and putted around in a low-mileage 1992 K-car, might be disturbed and upset. I thought the son was a controlling little freakazoid, but didn’t say so. Not very nurse-like, I know, but your humble writer smiled and nodded and went on, curiously enough, to validate and affirm the son’s distress even as the son was proceeding merrily along with the aforesaid ream spree.  Then I promptly charted the conversation because, as all nurses know, these things come back for endless amounts of arse-biting. My life as a nurse: Florence, eat your heart out.

Management Approaches with Nurses Week Greetings

Also, Acme Regional’s annual Token of Sincere Appreciation, a.k.a. the Swag Bag, has evidently been cancelled. So in other words they are replacing crap with no crap at all which, when I come to think about it, represents a net gain.

Hurrah.

Anyway, EDNurseasauras and I seem to be on the same page when it comes to Nurses Week. After listing all the cruddy, oddly depressing, and inevitably unattendable Nurses Week festivities at her workplace, she writes:

Bobo, our medical director and somewhat socially challenged on his best days has actually paid out of his own pocket for some nurses day gift (I think his wife is a nurse).  In the past we have received lunch bags, t shirts, and coffee mugs.  But slogans like “Nurses Call the Shots”,  ”Love a Nurse PRN”, “Nurses Rock” and other silliness goes right to the bottom of the charity bag for me.  Let me say that I truly appreciate that he has taken the time and effort to do this.  I really do. But I actually hate that more than the company logo.

At my nursing school graduation 35 years ago, one speaker exhorted us as newly minted nurses never to condone slogans that exploit us as men and women in health care, perpetuate stereotypes, and fail to present nurses as professionals.  Big boobs, thigh highs and stilettos, giant syringes…..you know what I’m talking about.  I have a few Emergency Nurses Association coffee mugs from a former boss that are tasteful, but other than that I say NO to silly slogans.

The only Nurses Week recognition I’m looking for is just a little sincere appreciation for the job I do from my employer.  Sincerity is not one of their strong points, so hopefully my boss will come through with the ice cream.

Ungrateful wench! At least she might get ice cream.

So how is your Nurses Week going?

How Nurses View Themselves

A selection of “What I Actually Do” meme posters” related to nursing, which have been making the rounds on the Interwebs. Some of them, I guess, are funny and clever, and they’re meant (I suppose) to educate the public at large about the realities of nursing. But what I think is interesting is the way they reflect nurses’ perceptions of themselves, and how nurses perceive how others view them. Some common themes: nurse as lazy (by managers), nurse as bimbo, nurse as angel, nurse as waitress/bellhop, nurse as money-grubbing, nurse as menial. What do you guys think of them? Do they actually represent how nurses view themselves?

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On Your Feet, Nurse, the Doctor’s Here!

Should nurses give up their chairs for physicians? A nursing professor named Susan Kieffer writing at NurseTogether.com thinks so:

If you have been a nurse for any length of time, you know how precious the seats at the nurses’ station really are. These seats are a rare commodity; one to be cherished and guarded once you snag one. It is also true that the coveted chair can be very revealing regarding the professionalism of the person occupying it.

Uh-huh. Kieffer goes on:

I will pose to you a question that I recently asked a class of students: registered nurses who are taking their first course in their journey to their bachelor’s degree and are studying the art of professional nursing. Many of them have been practicing nurses for 20 years or more. Here is my question to them: “As a professional courtesy, would you willingly and gladly give up your chair at the nurses’ station to a… to a… wait for it… a doctor?”

The old is new again

Really?

Kieffer goes on to argue that nurses are bigger than their ownership of their chairs by a mile. In other words, we’re better than those nasty physicians, even when they are nasty to us. I call Kieffer’s argument The Chair Strategy for Recalcitrant Physicians:

So, here is the point that I wanted to make with my students and will do so here as well: I believe that giving up that chair to the doctor shows the utmost in professionalism, courtesy, and confidence.

[SNIP]

Can we not be confident enough in our abilities and our practices that we do not feel like we have to prove ourselves by remaining seated while the physician stands? If a nurse gives up his or her chair at the nursing station to a physician, maybe even the very doctor who was disrespectful a few minutes ago, I believe that it shows that the nurse’s professionalism is a notch above the norm. It’s like taking the high road in the midst of mistreatment. Such professionalism could go a very long way in increasing the respect given to us in the health care community. Who knows… maybe our example will eventually lead to a physician offering his or her chair to US!

I know many of you are now rolling around on the floor in a display of unrestrained mirth. But stop it. Right now. This is a serious question, posed by one of our nursing betters leaders. And I will offer a serious and considered response.

My short answer is not only No, but Hell, No.

Two reasons: first, though I do have a streak of unreconstructed idealism a mile wide, I am not so naïve to believe that the Chair Strategy will ever cause physicians to respect us more. There is not enough Pollyanna in the world to make this possible. It isn’t as though physicians spend their sleepless nights agonizing over the burning question of Disrespectful Nurses. In any case, why (insert eye-rolling here) are we obsessing over what physicians think of nurses anyway?

And the Chair Strategy as the cure for bullying physicians? Please. Good physicians treat nurses professionally, with dignity and respect. Their opposite numbers are only going to be encouraged by subservience. Such physicians need to be called on their behaviour by assertive and confident nurses and if necessary reported to higher authorities, not coddled and enabled to be bullies.

My second reason has to do with the paternalism implicit in Kieffer’s article. I am not old enough to remember those halcyon days when nurses rose to their feet when the physician (in all of his god-like powers) entered the nurses’ station — no nurse would ever sit in the presence of a physician, God forbid — and when the charge nurse followed him on rounds, to open the door to ward rooms and take orders. But I am old enough to to have been educated by nurses who did remember those days, and their memories were not fond. The point of all the sitting and not sitting, giving up of chairs, and attending the physician like a pug dog follows a child was not “professional courtesy,” but a reminder of the power relationship between physician and nurse, and the place of nurses and nursing in the hospital hierarchy.

Kieffer misses this point. She ignores the obvious symbolism, that who gets to sit and who doesn’t speaks directly to hierarchy and deference to superior authority. Nurses who robotically and without thought give up their chairs are implicitly saying, “Here, doctor, take my seat, because what I am doing can hardly compare to the importance of your mighty role in the provision of health care.”

Let’s put this in practical terms: if I am sitting in the nurses station, I am charting or otherwise doing something requiring the convenience of seating. I am not going to offer up my chair to a physician qua physician for her or his convenience. The reason for this is simple: I have work to do. Which in the scheme of things, is as about as important for overall patient care as any physician’s. If you believe what you do is somehow of less importance or insignificant compared to a physician’s, by all means give up your seat. (Neck rubs for said physician are optional.) If you believe your time and convenience is at least as important of the physician’s, kindly yet firmly direct them to the consultants’ room — or any other alternate seating.

I will grant Kieffer this: she is right on the larger issue of professionalism. If nurses are sitting around texting or Tweeting or drinking coffee while looking over catalogues, by all means move if a seat is required. But that’s just common sense and courtesy, and not restricted for physicians alone.

One last point: does anyone know why, exactly, we are talking about nurses giving up their chairs for physicians, in this the year of God’s grace, 2012? Does anyone actually think Kieffer is correct?

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.]

Bedside Nursing as Menial and Demeaning

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

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

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

[SNIP]

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

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

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

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

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

Hmmm. Maybe not.

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

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

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

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

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

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

Because we have none. Or think we do.

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