Best. Comment. Ever.

Blog reader “Sarah” REALLY gave me a big old can of whoop-ass when she wrote something on my blog post “The Value of Nurses” She really schooled me! So take it away “Sarah”!

Nursing is critical to patient health and recovery. Nurses are responsible for the day to day care of the patient. 

Nurses are also useful for disease prevention and chronic disease management (trust me, MD wants to go to school 12+ training in the medical model of care to tell fat Type 2 diabetics they need to stop eating pie).

That said, yes nurses know how to do all the technical things listed. Respiratory threrapists [sic] can also expertly read EKGs, blood gases, and recognize heart sounds. As can paramedics. These things alone are not rocket science.

Nurses are never trained in pathology using the medical model of care to form a differential diagnosis of disease. Otherwise they’d be unhappy underpaid junior doctors. Try calling a nurse a para doctor and see what they say. Nurses seem to forget that the nursing model of care and training is a different role from MDs.

Sure nurses save lives and do some great things providing care for patients, but many other jobs do as well. Personally, if I have a disease, I’d be putting all my money into the MD/PhD in the lab trying to cure me vs a “good” nurse. I find most nurses can provide basic care but anything advanced is rightfully over their training. Good nurses recognize their limitations, not toot their own horn. So I gave up expecting competent nurses while in the hospital.

Yay so you can recognize a cardiac cycle or a hypoglycemic attack in your patient (how did you let the patient get that way in the first place?!). That still doesn’t mean you have knowledge worth $40 hr+.

Well Sarah, you are absolutely right. I was thinking just the other day about the time me and Doreen were sitting in the Resus Room playing cribbage for a nickel a point when Greta from Admissions walked by and said to us, “Hey, that monitor had some funny pointy lines.” We looked up and yep, she was right! So we talked it over— I was five dollars and two bits ahead — and we thought since he — the patient, I mean — was maybe in ventricular tachycardia we should call in Dr. Handsome. So we did and all of a sudden there was this big fuss, Dr. Eagerpants and Dr. Contentious and Dr. Fusspot came running in and started doing IVs and xrays and EKGs and catheters and everything. It was just like that TV show, House. Then I skunked Doreen and she got mad and left without paying me my five dollars and twenty-five cents which was now eight-fifty, and also the patient died. Dr. Handsome said sadly, “If only someone knew how to do an emergency cardioversion, we could have saved him!” and pounded his first on the Resus Room desk, just like on House. Haha. What a dummy! Like nurses can do anything like that!

Then there was the time Doreen and I were painting each other’s nails in Exams, and one of those nosey housekeepers told us the guy in bed 4 was throwing a seizure or something. And despite our wet wet nails we went over and looked and Doreen said he was! Then he stopped. I found out later he died. I guess he did something called, um, sounds like asparagus but isn’t. Dr. Handsome came in, and pounded his fist on the desk again. “If only someone knew how to give a benzodiazepine and also protect his airway we could have saved him!” he said. Doreen and me just looked at each other. What??? Nurses can do that??? But anyway I had to pee. I think on reflection we fell down a little on that one and definitely didn’t earn our $40+ an hour!

There are some other things too, so yes you are right, nurses should stick to wiping bums and leave the real doctoring to doctors, though RTs and paramedics can do some doctorings too sometimes. I will toot my horn though just a little, though! I once found some old lady had a fever once! So that was awesome!

Also, I once told a fat man with the diabetes he ate too much pie. Isn’t that kewl??? It’s like we psychically share a brain! But maybe you have it this week!

Thanks for writing!

A Blogger, Allegedly

So, it’s been awhile, eh?

It was Chuck Norris who found me.

To everyone who emailed and texted and Tweeted, thanks. Everything is hunky and dory. I’m not dead, ok? Let’s get that out of the way. Nor am I afflicted with a Chronic Debilitating Illness, unless you count members of my family. (That would be the topic of long separate blog post + extended psychotherapy.)

So what happened? Much to my surprise and amazement (and frank gratitude if truth be known) I got a new job about this time last year. A job with a very steep learning curve and a fairly cool boss with an alphabet soup of letters after her name and about as far away from Emergency nursing as you can imagine without leaving the hospital.

It is true, friends.

I have walked away from the front line.

I have drunk the mystical Kool-Aid.

I am Management.

But not real Management. I don’t actually manage anyone. I make up PowerPoints (ugh), give talks, and do research. I write policies. I have projects. I educate patients and staff.  I occasionally make recommendations to Important People many steps above my pay grade, When I do speak, the senior administration actually pays attention and sometimes will do this or that based on the words flowing out of my mouth. This is a bit of a revelation for a front-line nurse used to managers halfheartedly and reluctantly paying attention. OK, not really paying attention at all.

Nurse K once suggested to me that my ambitions for real management were probably misplaced. Having observed front-line managers from the other side up close for the past year, I have to agree. Being a front-line manager truly and deeply sucks. It’s far worse than being a charge nurse. (I say this as an embittered former old charge nurse, remember.) Awesome amounts of responsibility and no actual power. And navigating the snakepit which is hospital politics. And the risk of being walked off the property at will. Great job, right?

So first lesson: I think I dodged a bullet there. I really don’t want to be a manager.

Second lesson:  This is the first job where I use all of the skills I have acquired as a nurse in a meaningful and effective way.

I’m not just talking about clinical skills, or therapeutic communication skills which are surprisingly important in my current position; I’m also talking about evidence-based practice, critical thinking, leadership, understanding hospital processes, effecting change, teaching and developing clear presentations and a whole pile of other stuff — a whack of skills I acquired along the way in my ED practice.  The unfortunate fact is, the opportunities to develop and use all of these skill in front-line practice is limited. The fact I had to leave front-line practice to fully explore them is a telling, don’t you think?

Third lesson: Make the jump. I’m looking at all of you who think there must be more. Or better. Do something different. You won’t regret it.

Curiously enough a couple of days ago, someone named Darren Royds left this comment on one of my blog posts:

You need to get out and find a decent job. Have a life , live and reduce stress. I have quit nursing and was the best decision I ever made. You will end up as so many do.

Well exactly.  I haven’t quit nursing, though. But as much as I loved working in the ED, it was clearly time to move on. It was the best job decision I have ever made.

Have you guys ever made a career change to/from/within nursing? Was the outcome good/bad/indifferent?

 

 

P.S. So what about the blog?

That, dear friends, will be a topic for another blog post.

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.