Privacy, judgment and ethics aside, I have caring to do.

A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could.  I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.

I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby.  Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.

I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby.  I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before.  Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.

Charge Mommy

A few days ago, one of my colleagues said to me after a particularly frantic day in the ED, “You guys aren’t Charge Nurses, you’re Charge Mommies.” She is right. This is what we do:

• tell all the kids don’t fight and play nice

• fix boo-boos

• give hugs as needed, or tissue

• make sure all the kids get lunch

• find things

• repair broken toys

• clean up little “accidents”

• greet guests, and ensure they’re fed and comfortable

• make sure everyone keeps the place tidy

• assign chores

• deal with the unpleasant relatives upstairs

The one thing I don’t do is enforce discipline. No spankings or time outs. I have a Manager Mommy for that.

Treat the Patient Not the Disease

Abscesses and wounds, and especially abscesses and wounds which are infected, suppurative, purulent, and generally awful, are embarrassing for patients and difficult for nurses. Embarrassing for patients because they are disfiguring and smell badly, and difficult for nurses for really the same reasons. Personally I don’t mind caring for and treating wounds and abscesses, but I know plenty of nurses who would rather throw live kittens on a hot barbecue than go anywhere near a draining carbuncle.

Jennifer Olin over at RNCentral has an excellent blog post on caring for wounds. The first part of her post deals a little with the pathophysiology of wounds, the second on the providing good care to patients with wounds. Olin writes:

Well, we are likely the healthcare providers who will first notice the problem. It will be during a dressing change, or just when you enter the patient’s room—you know. The scientific side of nursing will to clean the wound, inspect it, chart it, and if it is bad enough, inform the wound care team or physician. But remember, I said you are likely the first healthcare provider to notice. Trust me, the patient already knows.

This is where the nurturing side, the compassionate side of nursing is brought into play. And, it’s not for the weak of stomach or, particularly, the weak of heart. Bad smells carry a social stigma along with the health hazards inherent in the wound itself. Wet, sticky, bandages are a sign for all to see that there is a problem. People with wounds in this state often suffer inhibited work, social, and sex lives and frequently have feelings of shame and depression.

[SNIP]

You learn little tricks to help you not react (breath through your mouth, use a minty lip balm).  Keeping the patient engaged is the key. Many of them won’t look at their wounds, won’t acknowledge there is a problem, or want to discuss it. You can teach them how to clean and dress their wounds, give them pamphlets and supplies, and help them plan future appointments but it is the emotional part of nursing that will often make the biggest impact on their healing and wellness.

Something we (remember?) were all taught in nursing school was the holistic care of the patient, that is, caring not only for the physical complaint of the patient, but also for the emotional, spiritual, social and even economic needs of the patient. Good wound care exemplifies nursing care in a microcosm. So when nurses see a patient with a decubitus ulcer, what do they see, the wound or the patient? Our inclination, of course, is to see the wound, somehow detached from the person bearing it, a way of thinking exacerbated by seeing nursing as a series of tasks to be completed rather than a holistic process involving critical thinking. Olin’s article, in this context, is a good reminder that in the end, we should be treating the patient, not the disease.

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?

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.

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?

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.

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.