Archive for January, 2012
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Nursing Naval Gazing, Random Thoughts on Tuesday 31 January 2012
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.
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.)
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.)
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.”
An Old Man’s Winter Night
All out of doors looked darkly in at him
Through the thin frost, almost in separate stars,
That gathers on the pane in empty rooms.
What kept his eyes from giving back the gaze
Was the lamp tilted near them in his hand.
What kept him from remembering what it was
That brought him to that creaking room was age.
He stood with barrels round him—at a loss.
And having scared the cellar under him
In clomping there, he scared it once again
In clomping off;—and scared the outer night,
Which has its sounds, familiar, like the roar
Of trees and crack of branches, common things,
But nothing so like beating on a box.
A light he was to no one but himself
Where now he sat, concerned with he knew what,
A quiet light, and then not even that.
He consigned to the moon, such as she was,
So late-arising, to the broken moon
As better than the sun in any case
For such a charge, his snow upon the roof,
His icicles along the wall to keep;
And slept. The log that shifted with a jolt
Once in the stove, disturbed him and he shifted,
And eased his heavy breathing, but still slept.
One aged man—one man—can’t fill a house,
A farm, a countryside, or if he can,
It’s thus he does it of a winter night.
— Robert Frost (1920)
A surprisingly creepy little film, if you have twelve minutes and thirty seconds to spare.
A note sent to me from my favourite MRT (Medical Radiation Technologist). A reminder too, that nurses aren’t the centre of the universe, even if we think we are.
Some thoughts from an MRT. . .
If a portable examination is requested it’s because the patient is too ill to come to the department, not because they are in the bed nearest the window and it’s a hassle to get them out of the room. Portable exams give less information than a department film so why chose inferior diagnostics?
So the patient is too sick to leave the floor might there be a need for a nurse to help the MRT with the patient? Just saying, just wondering. Now this help isn’t for the MRT’s benefit – though lifting and maneuvering people one handed is tricky – it’s for the patient.. Even if your patient is sitting bolt upright and square on do you think it’s a kindness to have them pulled forward by one arm as the heavy cassette is placed behind them? Because this is what the MRT has to do if the patient can’t lean forwards.
Oh and please don’t all run the minute the portable machine comes trundling down the corridor. It isn’t radioactive. And if you don’t have time to move 2 chairs, a commode, a walker, and a couple of tables out of the room what makes you think the MRT does??
You know if you help with the exam then I’ll help put everything back in it’s place.
In Emerg, when you call the tech for a stat film then do acknowlede ge them when they arrive, and maybe even stay to help, (see above re too sick to go to the department.) If you don’t hang around then do answer the tech when they ask if the patient can be sat up for the film, or have any other questions about your patient.
Points well taken. Remember it’s about the patients, right? I’m pretty sure too other health care professionals have similar valid gripes about us. Ladies and gents, we need to pull up our socks.
Some Chinese New Year fun.
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.
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 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.
A pretty interesting video from Beth Boynton RN on what I call status interrupticus, the incessant and often needless interruptions nurses deal with when performing duties requiring critical thinking and judgement. It’s fairly well known, for example, at among nurses anyway, that many if not most med errors are attributable to nurses being distracted; I myself, during a code or trauma have sometimes reached for the wrong drug. In any case Beth nicely relates the problem to larger issues of healthy work places, meaningful nursing and professionalism. Worth a look.