Archive for September, 2013

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!

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Where does the Rot Start in Nursing Home Abuse?

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Let’s take a look at the Mission and Values statement of the nursing home:

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

Living
St. Joseph’s at Fleming is committed to creating a healthy living and working environment that:
[. . . ]

• Treats people with fairness and social justice

[. . . ]

Learning
St. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

Caring
St. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness 
• Integrates best practices and innovative solutions
• Promotes individuality as well as personal and spiritual growth 
• Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients?  How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?

Yes.

The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

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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.

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