Archive for May, 2012

Favourite Poems LV: If You Forget Me

If You Forget Me

I want you to know
one thing.

You know how this is:
if I look
at the crystal moon, at the red branch
of the slow autumn at my window,
if I touch
near the fire
the impalpable ash
or the wrinkled body of the log,
everything carries me to you,
as if everything that exists,
aromas, light, metals,
were little boats
that sail
toward those isles of yours that wait for me.

Well, now,
if little by little you stop loving me
I shall stop loving you little by little.

If suddenly
you forget me
do not look for me,
for I shall already have forgotten you.

If you think it long and mad,
the wind of banners
that passes through my life,
and you decide
to leave me at the shore
of the heart where I have roots,
remember
that on that day,
at that hour,
I shall lift my arms
and my roots will set off
to seek another land.

But
if each day,
each hour,
you feel that you are destined for me
with implacable sweetness,
if each day a flower
climbs up to your lips to seek me,
ah my love, ah my own,
in me all that fire is repeated,
in me nothing is extinguished or forgotten,
my love feeds on your love, beloved,
and as long as you live it will be in your arms
without leaving mine.

— Pablo Neruda

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Nursing Week Ain’t What It Used to Be

My Nurses Week joy was shattered last night when the son of a patient reamed me out for discussing the patient’s condition and treatment plan — wait for it — with the patient. He thought his father, who was a rather elderly but very independent and shrewd man who still lived in his own house and putted around in a low-mileage 1992 K-car, might be disturbed and upset. I thought the son was a controlling little freakazoid, but didn’t say so. Not very nurse-like, I know, but your humble writer smiled and nodded and went on, curiously enough, to validate and affirm the son’s distress even as the son was proceeding merrily along with the aforesaid ream spree.  Then I promptly charted the conversation because, as all nurses know, these things come back for endless amounts of arse-biting. My life as a nurse: Florence, eat your heart out.

Management Approaches with Nurses Week Greetings

Also, Acme Regional’s annual Token of Sincere Appreciation, a.k.a. the Swag Bag, has evidently been cancelled. So in other words they are replacing crap with no crap at all which, when I come to think about it, represents a net gain.

Hurrah.

Anyway, EDNurseasauras and I seem to be on the same page when it comes to Nurses Week. After listing all the cruddy, oddly depressing, and inevitably unattendable Nurses Week festivities at her workplace, she writes:

Bobo, our medical director and somewhat socially challenged on his best days has actually paid out of his own pocket for some nurses day gift (I think his wife is a nurse).  In the past we have received lunch bags, t shirts, and coffee mugs.  But slogans like “Nurses Call the Shots”,  “Love a Nurse PRN”, “Nurses Rock” and other silliness goes right to the bottom of the charity bag for me.  Let me say that I truly appreciate that he has taken the time and effort to do this.  I really do. But I actually hate that more than the company logo.
At my nursing school graduation 35 years ago, one speaker exhorted us as newly minted nurses never to condone slogans that exploit us as men and women in health care, perpetuate stereotypes, and fail to present nurses as professionals.  Big boobs, thigh highs and stilettos, giant syringes…..you know what I’m talking about.  I have a few Emergency Nurses Association coffee mugs from a former boss that are tasteful, but other than that I say NO to silly slogans.
The only Nurses Week recognition I’m looking for is just a little sincere appreciation for the job I do from my employer.  Sincerity is not one of their strong points, so hopefully my boss will come through with the ice cream.

Ungrateful wench! At least she might get ice cream.

So how is your Nurses Week going?

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Nurses Practice Beyond Their Scope — And It’s Not a Bad Thing

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”
[SNIP]
[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.
Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious —  that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of.  We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.

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*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours.  That’s a pretty big chunk of time, and in a busy department, is not going to happen.  And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

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Alzheimer’s Is Not Funny — Or Is It?

Via Osocio, a teenage sociopath scams his Alzheimer’s-afflicted grandmother — and manages to raise the age-old question: are some conditions simply not funny?

Admittedly, a small giggle from me. But I am an unreconstructed ED nurse, remember?

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Favourite Poems LVIV: The Curate Thinks You Have No Soul

Was thinking, by-the-by, about some dogs I have loved, and how I get along with (and like, if truth be known) dogs better than most people. So sentimentalism be damned: here’s a dog poem.

St John Lucas was an early 20th century anthologist of poetry and friend and mentor to Rupert Brooke.

The Curate Thinks You have No Soul

The curate thinks you have no soul;
I know that he has none. But you,
Dear friend, whose solemn self-control,
In our foursquare familiar pew,
Was pattern to my youth — whose bark
Called me in summer dawns to rove —
Have you gone down into the dark
Where none is welcome — none may love?
I will not think those good brown eyes
Have spent their life of truth so soon;
But in some canine paradise
Your wraith, I know, rebukes the moon,
And quarters every plain and hill,
Seeking his master. . . As for me,
This prayer at least the gods fulfill;
That when I pass the flood and see
Old Charon by the Stygian coast
Take toll of all the shades who land,
Your little, faithful, barking ghost
May leap to lick my phantom hand.

— St John Lucas

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Friday Night Flicks: Fallen

Reminds me of this passage from Marcus Aurelius’s Meditations: “Pass then through this little space of time conformably to nature, and end thy journey in content, just as an olive falls off when it is ripe, blessing nature who produced it, and thanking the tree on which it grew.”

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

… and other examples of nurses eating their young…

A few statements I’ve heard in the last few years that I shall share periodically.

“It is more important that I get all of my breaks than you young folk because I’m older and need to rest more often”

I fail to understand how one person’s break is more valuable than anyone else. I realize that to-the-death cage matches can occur for which nurse goes first when it’s crazy busy, but seriously, just because you are senior staff does not make you superior and priority when it comes to a moment to stop, eat, go to the bathroom, etc. I like to think we are all the same as department staff members (obviously not including experience or department responsibilities for example…) but everyone is entitled to their break. Years of service to the hospital should not, in my mind, make you first up for every break.  I often see the charge nurses getting fewer breaks than the rest of the staff (which is unfortunate) because they are trying to see that everyone else is getting a chance to eat. And for the most part, the charge nurses are all very senior staff. If you cannot keep up with the pace and demands of a busy emergency department or other job area and feel you cannot miss any breaks because of your age then perhaps you need to work in a different environment. Or retire. Missing breaks sucks no matter what way you look at it, but we have to work together to ensure we’re all taken care of.

  • I do make the exception however for those with medical conditions, such as diabetes or a pregnant staff member (which is not a condition albeit) who is carrying/growing another human being inside of them. I have never personally grown a human, but from what I have observed, it’s tiring and your body needs extra food and having your lower legs elevated for a period of time in the day (that may have become the size of my thighs) is important too. So I personally would not have any issue with offering them the first available break.
  • please also note that this does not in any way encompass all senior staff. Just the few that can be particularly nasty.

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If You See a Teddy Bear, Shoot It

That would be the taste of barf in my throat

Nurses Week is fast approaching. I am steeling myself  mentally for the steady drizzle of syrupy tributes from various health care apparatchiks and functionaries, who will inevitably make some reference to nurses as “angels” and the “beating heart of health care” or some such tripe. I have yet to see an article this year illustrated with a teddy bear dressed up as a nurse, but it is early days yet. A reminder: if anyone approaches you with such a teddy bear in recognition of Nurses Week, do not look the bear in the eye, but instead beat it against a hard surface till the stuffing flies out, or the honour of the nursing profession is restored, whichever comes first

(In case you are new to this blog, here’s why I hate teddy bears and Nurses Week so much. Well, not so much hate, but a deep visceral loathing.)

I was put in mind of all of this reading some of Nurse Keith’s old blog entries over at Digital Doorway. I came across this post, which pretty well sums up my feelings about the association of teddy bears and angels with nursing, and also their use in scrubs. Nurse Keith wrote:

Somewhere along the line, the “angels of mercy” moniker became attached to nurses as a group. Granted, in the early days of nursing, nurses’ ability to act autonomously was extremely limited, and we were, by and large, the handmaidens of deified doctors. However, as much as that regrettable history has largely changed, the image of the nurse as angel unfortunately persists quite widely in our culture and websites galore promote gifts and baubles that continue to diminish nurses’ professionalism. Images such as this one drive home the point: nurses are childlike individuals with starched white hats who love teddy-bears. Adding insult to injury, nurses can actually be depicted as winged angel/teddy-bears, further enforcing the infantilization (and deprofessionalization) of our profession. Would doctors allow themselves to be thus represented to the public?
Rather than being perceived as cherubic angels and childlike creatures, this writer feels that being perceived as the valuable and skilled professionals who we truly are would allow the public to have a much more accurate perception of what we do, and our importance to the care of millions.

[. . .]

Nurses’ uniforms have certainly changed over the years, and as scrubs have become the norm for nurses in most clinical settings, many companies have capitalized on the popularity of such utilitarian clothing. Now, designer scrubs covered with angels, teddy-bears (there they are again!), and any number of cartoon-like images adorn the hard-working bodies of nurses around the world. If nurses want to be taken seriously by the public—and by doctors and other professionals—how does the wearing of such (in my opinion) unprofessional clothing help our cause?

Shoot on Sight

Picture this: a team meeting occurs midday to discuss a patient on the adult oncology floor. Present at the meeting: a medical resident, a medical student, the attending doctor, the oncologist, two unit nurses, a social worker and a respiratory therapist. Of all of the professionals in the room, who would possibly be wearing pink scrubs covered with teddy-bears and hearts, and a pin on her chest saying “Doctors Cure, Nurses Care”? And what message does this convey about the nurse’s self-image and how the other professionals present in the meeting should perceive him or her?

Well exactly. Imagine you’re dressed in an angel-motif scrub top, and you’re trying to give discharge instructions to a patient. Do you really think the patient is going to take you seriously? Really? Or you’re trying to get the physician to order more narcotic analgesia dressed in deep rose pink scrubs, a colour, I admit, which makes me do the inward cringe every time I see a nurse wearing it. Does that deep rose pink convey to the world the exact amount of professionalism and intelligence nurses believe they possess?

I guess I am wondering if there anyone out there willing to defend the whole nurse/teddy bear/angel thing, or even say three cheers for teddy bear scrubs or even frilly “feminine” scrubs?

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