Nursing Makes Nurses Less Empathetic

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

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

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

Ouch.

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

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

 

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.

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.)

 

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.

Karma Sweet Karma

The latest instalment of Nurses Behaving Badly featured the night charge and the day charge (i.e. me) getting a status asthmaticus organized in Resus 1 a few minutes after shift change. It’s probably reasonable to wonder why the two Resus Room nurses weren’t attending (and attentive to) the situation, especially after we paged the physician and the RT in quick succession for a possible intubation, and especially since both of them were less than twenty feet from where we were working.

We thought at first they were getting report on the only other patient in Resus, but after 10 minutes or so we began to wonder how long it actually takes to give report on a stable, routine, admitted, pain-free NonSTEMI.

Meanwhile we got the patient on high-flow oxygen, assessed, drew blood, did an ECG, set up stacked Ventolin treatments, placed two large bore IVs, hooked the patient up to the cardiac monitor and generally got organized to tube the patient.

Turns out they were looking at a jewellery catalogue, drinking coffee, texting, socializing, what have you.

Grrrr. And when the night charge asked our two colleagues to cease and desist from shopping and tweeting and trading bon mots and actually do some, you know, nursing, we got the “whatever” look: face squinched up, hands up in the air, eyes rolled. The look that manages to convey a dishful of entitlement and irritation, with a light sauce of fuck you to complete.

Double grr.

By the time I gave my report, it was nearly an hour after shift change. But what goes around comes around. There is cosmic retribution and it is just.  That night Nurse Tweedledee and Nurse Tweedledum received, in addition to the now intubated status asthmaticus:

A cursing psychotic patient in four point restraints

A cursing drunken 20-year-old who managed to pee and puke all over herself all at once

A VSA*

Another VSA

A non-compliant insulin dependant diabetic in DKA 

And just before shift change, a fulminating CHFer, which required them to stay long after their shift was over.

In short, they had a craptacular night. The complaints, the bitterness, I am told, from the pair was tremendous. They needed to leave. They had child care issues. Husbands needed vehicles — and one of them was written up for being late. They were tired as no nurse in the history of the universe was tired. Why are we so afflicted? they moaned. What did we do to deserve this?

Karma, baby, karma.

The cosmic lesson being simple, work starts promptly on the hour. Not after fifteen or twenty minutes of “social” time. Be considerate of your colleagues. They’ve been working for twelve hours and want to go home. Many, many, bonus points if you come in ten minutes before to get report so the nurse you’re relieving can get out on time.

To say I had any sympathy for either of them would be a bald lie. Can you say schadenfreude?

 

___________

*VSA = Vital signs absent.

 

 

What Nursing Leadership Doesn’t Look Like

A small, belated Christmas tale on how not to manage an emergency department. But first a few preliminary points of information.

First: in Ontario, front line nurses are generally forbidden from taking vacation over the Christmas holidays, usually from some point from the first or second week of December to the first or second week of January. There are a couple of reasons for this: first, there are always staffing issues over Christmas. Secondly, if vacation time is granted by seniority, and if it werepermitted during the Christmas break, the most senior nurses would always get Christmas and New Year’s off, making merry while leaving their more junior colleagues to toil through the happiest time of the year. Hardly fair, and scarcely a morale booster.

My emergency department, Boxing Day

Most hospitals in Ontario will arrange scheduling in this way: nurses work either Christmas or New Year’s (either we pick or alternate each year) but we get five or six days off in a row over the holidays. Like any compromise, it inconveniences some people, but most seem happy about this arrangement.

Second: most Emergency departments over the holidays look like a merger of Bedlam and a random circle of hell from Dante’s Inferno. High acuity and high volume. I might add this holiday season war zone ambience is as predictable as, well, Christmas falling on the 25th of December. We just gird our loins and sally forth. Nevertheless, even halfway through January, we’re all a little crusty and stressed out.

So what would you say to a manager who takes vacation — and not a short one either — over the Christmas holidays? One of my minions has informed me that an ED manager at one Toronto-area hospital took vacation from roughly the middle of December to the middle of January. Needless to say, given all of the above, her staff are not impressed. They are angry. They felt abandoned at a time when leadership was needed. They resent the double standard, the flaunting of the no-vacation-over-Christmas rule. Some of them, I’m told, are so disgusted by this behaviour that they are actively seeking positions elsewhere.

I understand that managers deserve and are entitled to their vacations, and that from a staff nurse’s point of view of there may be no good time for a manager to take time off. Even so, taking vacation when staff cannot, and over time period when volumes and acuity are notoriously high indicates a certain amount of  — what? — cluelessness?

Management does have its privileges, but also has responsibilities. To me responsibility means sticking it out and providing leadership to your staff, even when it’s personally inconvenient. It might mean delaying a vacation for a month. It means not bailing out when you know things are going to be awful. This is good nursing leadership. Or am I completely off base about this?

UPDATE (22/01/12): Minor edit of mispelling. I need an editor, but can’t afford one.

O Why O Why Did I Pick Up The Phone?

Phone rings.

I look around.

There is no ward clerk in sight.

Damn.

I answer. “Emergency, Charge Nurse.”

“Can I ask you a question?” The voice on the other end sounds flat and tired.

“Sure,” I say warily.

“I came to see you guys a three days ago and I had a sore chest and you guys did a whole bunch of tests even though I told you my Ventolin had run out and my asthmas was real bad, and you did nothing for it, and the nurse was real rude, like, and you guys took blood and, and did a heart test I did an xray, and I was real afraid of the xray ’cause of the radiation, and I don’t want to get cancer or nothing ’cause i already got cancer like my mother who died of breast cancer and the doctors didn’t do nothing, and then the doctor told me I had an infection in my chest and I think it he said it was pneumonia and he gave me a prescription and I got it filled and I took the first dose tonight, and it didn’t do nothing, and now I have a rash on my arms and stomach and it itches real bad —” The caller paused for breath.

I jump in, wondering where exactly the question lay. “Are you asking for medical advice?”

“I guess. Can you help me?”

“We don’t give out medical advice,” I say. “You can call Telehealth, and they should be able to. You have pen and paper and I’ll give you the number?” I think, please let me give you this number, so I can end the call. She’s not having any of it.

“Are you guys busy?”  she asks. Every emergency nurse knows this question, and we all have the same answer.

“I can’t answer that,” I say. ‘It depends on how sick the patients are, and how many people come into the emerg.”

“How long is the wait?” she persists. “Will I have to wait long?”

“I can’t answer that, ” I repeat.

“Can I pre-book an appointment?”

“I’m sorry, no.”

“Well, thank you for fuck all!” She bangs the phone down.

Thanks and you’re welcome, I mouth. Another happy customer who has made me very glad to be a nurse. And ten minutes of my life gone for ever. I swear I will never pick up the phone again. Really. I mean it.

The phone rings.

I look around.

There is no ward clerk in sight.

Damn.

In Which TorontoEmerg Discourses on Some Aspects of Human Nature

It’s probably more than little trite to say the Emergency Department is a microcosm or laboratory of humanity, but like most clichés it has an element of truth. We see all types in the ED, the good, the ugly, and the purely despicable. (And then I could talk about the patients.) We’re human, after all. But in general, ED staff are as generous and warm-hearted as anybody anywhere. For example, when one of us is injured, or has a death in the family, or is seriously ill, we’ll take up a collection, and sometimes we raise surprisingly large amounts of money. Enough is donated, usually, to cover incidental expenses, and to keep our colleagues in need well-supplied with parking passes and Timbits while getting cancer treatment (for example) at Princess Margaret.

Well and good. Very nice. Pat on the back and warm fuzzies and Hero Medals for everyone.

A recent counter example: a colleague diagnosed a little while ago with a very serious and probably terminal illness. Fine, I said when I learned this coming into work. Where’s the envelope?

Blank stare.

What envelope? came the reply.

“You know, I said, “the collection envelope.”

“Oh, there isn’t one.” An embarrassed laugh. “You know, Jane is really irritating and no one really likes her.”

I got it. In my ED, evidently, supporting and helping a colleague is a popularity contest. If you’re well-liked and “one of the girls,” it’s roses and wine and parades. If not, you get the proverbial lump of coal in the stocking. Jane, it seems (a little sadly) had anticipated all of this voiceless nastiness, and was refusing visitors from all but her closest friends. Yes, we aren’t that far away from high school after all, and nourishing a sense of compassion evidently doesn’t rate very high on self-improvement.

My nurse colleagues are smart and engaged and have empathy by the yard. I love them all for their exquisite skills in nursing, but sometimes I really don’t like them much at all. This would be one of those times.

Also: this only goes to prove the point that nurses aren’t angels. They can be jerks and asshats like anyone else.

Flattery Will Get You Everywhere

It’s been a tough couple of weeks for Team TorontoEmerg. First, I’ve been working like a rented mule, and secondly, a colleague whom I trusted and respected sandbagged me with a nasty and embarrassing (and devastating) personal attack, which frankly put me in a bit of a tailspin. How bad was it? Think about being whacked hard across the face a couple of times with a 1″ bamboo pole, and you might get the idea.* I mention this not to whine — believe me, Mr. J. Doe has heard plenty of that — but merely to point out that life in the ED is tough enough. I mean it’s enough to face barking physicians, nurse managers who call us to their office only to reprimand, educators lying in wait to point out the merest flaw in our professional practice, not to mention the general opprobrium of our nurse-colleagues eager to pounce on any failure, without dealing with craptastic personal attacks as well.

Yes, today I truly love my profession. If I tell myself that enough, will it make it true?

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On the other hand, I got three compliments in the last two days, and if you’re an emergency nurse, you know that compliments from anywhere are as sweet as rainfall in a desert. First was  personal. A conversation I had with a patient during one of the rare days I actually was doing something clinical:

Patient: I’ve been coming to this hospital, I’ll bet, since before you were born.

Me: (fiddling with an IV) When did you start coming to Acme Regional?

Patient: 1971.

Me: Hehehehe.

Okay, silly and obvious. But oh-so-welcome. And then another patient told me flat out my care was exceptional. And then a management muckety-muck told me my name had come up during a meeting of even higher muckety-mucks. I am, apparently, attracting attention in a positive way in relation to the administrative secondment I’ve been doing. All of which takes away the sourness of the above. A little, anyway.

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I work with a nurse who in nearly every respect is a superb nurse. She’s clinically smart, knows her theory, advocates for her patient and provides excellent care. I was getting report from her the other day, and she was griping how this nurse didn’t do that and that nurse didn’t do this, and it occurred to me she has never, in my experience or hearing, said anything kind about any other nurse. Not ever. It’s almost pathological. I always come back to this question: how can nurses give exceptional care to their patients and then turn around to model themselves as fine examples of human malice? Does anyone have an answer that doesn’t involve a disquisition on horizontal violence and unequal power relationships in hierarchies?

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To my nursing colleagues, I have one request. Next time you’re on duty, or if you’re on duty as you’re reading me, go compliment one of your colleagues. Praise a difficult IV start or a successful catheter placement or some little piece of good nursing care. Do it. Right now. Trust me: by this one small act you’ll improve our profession immensely.

And then when you open your mouth to criticize or find fault with a colleague, find something else to say. Preferably something nice. Really. It’s not that hard. Remember how you felt when you were last sandbagged? And also, you’ll find here the difference between being a good or even superb nurse, and being an exceptional nurse —- and who doesn’t want to be exceptional?

__________

*So nasty, in fact, I’m seriously considering leaving Acme Regional. Why do I want to work within twenty miles of this person? The emotional response, I suppose, but one which is honestly how I feel, right now. Ask me again in two weeks.