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?

 

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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?

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Protect Your Love

Via Osocio, a very likeable ad for HIV prevention and awareness from the Toronto-based Alliance for South Asian AIDS Prevention. Osocio notes the ad is less about sex than and more about love, and in this way, I think, it manages to get its message across effectively, without being preachy or didactic.

(Incidentally, the short scene filmed in the Scarborough RT is very funny.)

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Favourite Poems LVII: Death

The first two lines — “Because I could not stop for Death,/He kindly stopped for me” — must be among the greatest opening lines of any poem.

Death

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.

http://zhurnaly.com/images/zhurnalnet_z_images/emily_dickinson.jpg

We slowly drove, he knew no haste,
And I had put away
My labor, and my leisure too,
For his civility.

We passed the school, where children strove
At recess, in the ring;
We passed the fields of gazing grain,
We passed the setting sun.

Or rather, he passed us;
The dews grew quivering and chill,
For only gossamer my gown,
My tippet only tulle.

We paused before a house that seemed
A swelling of the ground;
The roof was scarcely visible,
The cornice but a mound.

Since then ’tis centuries, and yet each
Feels shorter than the day
I first surmised the horses’ heads
Were toward eternity.

— Emily Dickenson

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When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

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The phrases junior nurses and most staff do not care to hear from senior nurses…

…or the negativity they can spew….

“You wouldn’t know what to look for in that type of patient assessment anyways…”

How do you know I don’t know what to assess for? Are you the textbook I read from? The online periodicals I continue to educate myself with? Are you every patient I have assessed in the last 8 years? Did you teach me? Were you my preceptor in some nightmare? Well since you are none of the previous and you’re not a bound textbook (despite how wound up you are all the time) please do not assume that since I have less experience than you, I won’t know how to assess a patient with XYZ diagnosis. Perhaps just ask if I know what the presenting signs and symptoms may be and any associated complications to monitor for, what the normal would be, etc… and take a supportive and educative approach if you are concerned about my assessment skills without any condescending tone or implied disregard for my apparent limited knowledge.

I recently had a patient with a skull fracture, (the head injury happened a day earlier), and the senior nurse asked if the patient had battle’s sign, (bruising behind the ears), which they did not, I informed her, to which she rudely replied with, “you wouldn’t know what battle’s sign looks like anyways…”. Between being 0645 in the morning after a long night shift and the only words coming out of my mouth would have been immature and highly offensive, I felt it right to walk away from the conversation.

As per this blog post, I’m clearly still stewing.

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Friday Night Flicks: Pigeon Impossible

No pigeons were harmed in the making of this short film.

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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?

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Epic Hitler Emergency Department Charge Nurse Rant

I never thought I’d use the words “Epic” and “Hitler” and “Emergency Department” and “Charge Nurse” and “Rant” as a blog title, but what the hell. I was bored one night and thought it would be fun to make a Hitler rant parody.

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Jean, ROSC*

So as J mentioned before, I was in a near catatonic state due to my VSA* computer which has fortunately been resuscitated. The hypothermia post resuscitation care was beneficial but it suffered an anoxic brain injury that may not be possible to overcome. Despite this crushing blow (more so financially really since I do not feel like purchasing a new computer) I am okay with the periodic laptop confusion for now. I’ll do neuro vitals qshift on the computer, continue monitoring and provide supportive care. (Sorry for the lame nurse humour; that I cannot fix.)

Aside from my near death computer experience I have been incredibly busy with working in the ER, updating necessary work courses, school work for a critical care course I’ve been taking as well as starting in Acme Regional’s CCU/ICU. It’s a very different world up there (literally not figuratively. . .it’s on the 4th floor). The pace will take some getting used to. On one hand I enjoyed just having one patient to dedicate time and care to, knowing their history and the pathophysiology of their recent admission and not feeling like I’m practicing unsafely or providing my patient with the bare minimum, however, at the same time, having only one patient is a bit boring. The ICU seems a bit tedious: lots of little details and new physician orders that my emergency brain isn’t wired for. We have a lot of autonomy in the ER, more then I think we realize. Either way, I welcome the change in general, be it pace, environment, meeting new people, learning some new skills and learning in general. I had been feeling stagnant in the ER for a while. I still enjoy the ER immensely and I am not leaving, simply picking up some hours in the ICU for now. If anything I hope the added critical care experience makes me a better nurse. I felt like I had hit a roadblock and I wanted to know more but I just wasn’t learning in my day to day work life, so back to school I went!

I’ll have some new posts soon on more phrases junior nurses and most staff do not care to hear, as well as some other burning ideas and issues (with possible sarcasm and complaints) that have been on my mind.  I have a few patient stories I’d like to share also. So, I hope to be more active soon, sorry for the absence!

*VSA – vital signs absent
*ROSC – return of spontaneous circulation

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