Archive for category Acme Regional Health Centre

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

…or the negativity they can spew….

“You wouldn’t know what to look for in that type of patient assessment anyways…”

How do you know I don’t know what to assess for? Are you the textbook I read from? The online periodicals I continue to educate myself with? Are you every patient I have assessed in the last 8 years? Did you teach me? Were you my preceptor in some nightmare? Well since you are none of the previous and you’re not a bound textbook (despite how wound up you are all the time) please do not assume that since I have less experience than you, I won’t know how to assess a patient with XYZ diagnosis. Perhaps just ask if I know what the presenting signs and symptoms may be and any associated complications to monitor for, what the normal would be, etc… and take a supportive and educative approach if you are concerned about my assessment skills without any condescending tone or implied disregard for my apparent limited knowledge.

I recently had a patient with a skull fracture, (the head injury happened a day earlier), and the senior nurse asked if the patient had battle’s sign, (bruising behind the ears), which they did not, I informed her, to which she rudely replied with, “you wouldn’t know what battle’s sign looks like anyways…”. Between being 0645 in the morning after a long night shift and the only words coming out of my mouth would have been immature and highly offensive, I felt it right to walk away from the conversation.

As per this blog post, I’m clearly still stewing.

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Registered Nurses won’t make newspaper headlines, but your local sports pro will

Click to enbiggen

With Ontario’s Nursing Week approaching, May 7 – 13, posters for the Ontario Nurse’s Association (ONA, our union) campaign on supporting nurses the same way pro-athletes are have been put up around Acme Regional.

The conversation often arises among my colleagues about how a baseball player can make over 20 million dollars a year where 3 or 4 nurses’ lifetime salaries combined will never compare to that. I often feel bitter when I think of those in the business world who receive all sorts of financial and personal incentives for their work. People who go on all expense paid trips because they have sold the most insurance (selling you safety nets in case you fall, but you likely won’t, however you have to have it…) for example that year, meanwhile in that same year I may have resuscitated a child, held the hand of a dying man during his last breath and treated a father of 4 for a heart attack among caring for other incredible people. I received my same pay as always and more importantly, do not expect an incentive. I don’t feel bitter that I’m not getting a trip, I feel bitter that in this society, a pro-athlete or businessman is more supported than nurses. On the other side of the coin, it makes me wonder what sort of nursing culture would be bred if nurses were provided incentives for life saving measures or actions/treatment/education. And what treatments or care would be deemed “more important” than others, garnering a higher incentive? In the emergency department health teaching is imperative; to prevent illness and disease so one could argue that is as important as treating the patient having a stroke. If incentives in nursing existed would the wrong sort of people be attracted to the nursing profession? Some say it’s a calling, the art of the practice; only certain people can and will do the job and do it well have you. It would be worrisome to think that an individual would only want to save a life or teach parents about how to appropriately treat fevers if it meant they would get a financial bonus.

And yet, despite all of this, I still struggle with the fact that people who sell the most cars, buy the most stock in a company, etc… are seemingly more valued and appreciated then those that save lives, give people more time on earth and genuinely (most of us at least) care about humanity. I have a hard time finding the balance in it all. Emergency nursing is in the “business of life saving” is it not? With more and more facilities receiving incentives for improved and rapid physician to patient initial assessment times, where does appreciation for the nurses fall in to all of this?

(See also ONA’s website here and RNAO’s website for nursing week.)

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Those Emergency Blahs

I’ve worked as an Emergency Department nurse for something like thirteen years now, and at my present position more or less for ten years.  It’s probably safe to say I’ve seen just about everything from the incredible tragic to the incredible funny, the good, the bizarre and the ugly. As I’ve said before, I’m blessed to have one of the coolest jobs around, and lucky to do something I can (sometimes) feel passionate about. Last few weeks though, I’ve been really out of sorts. The bloom is going off the rose. Can’t quite put my finger on it. Sense of general dissatisfaction? Bored? Just plain tired? I don’t know. My colleagues are really starting to annoy me, where before I could look upon their foibles with a sense of humour and plain tolerance, and I am starting to think I’m annoying the shit out of them as well. I come in some days, look at the staffing line-up and wish I had called in sick. The patients lately seem to be rude and hostile, or more so. Every problem seems to take massive amounts of time and energy to fix, and Acme Regional’s bureaucracy seems more obtuse than ever. Every little piece is taking its toll, and I don’t seem to have the reserves anymore to make up for the loss.

Bleh. 

I’m not tripping the light fantastic anymore.

Fact is, I’m starting to dread going into work at all. Signs and symptoms of burnout? I have ten days holiday coming up shortly. After that break, maybe I’ll have some perspective. But I’m thinking it’s time to go and do something else.

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Death to PowerPoint and Other Notions

Back again.Yeah, I’ve been away for a while, for reasons that have absolutely nothing to do with writing or blogging. However my unintentional sabbatical has had the benefit of leaving me refreshed and full of ideas and so maybe wasn’t such a bad thing after all. I mean, in the two years I have operated this blog, I’ve written something close to 700 (!) posts, so maybe a break was in order before my brain turned into cranial equivalent of this.

So what have I been doing? A little of this and a little of that, but mostly working at the administrative-type secondment I’ve been assigned to for the past few months. I’ve worked closely with a group of other nurses, which I have been thinking lately resemble the Seven Dwarves. Their names are Pouter, Shouter, Passive-Aggressive, Bashful, Grumpy, Beautiful, Grandma, and of course, we have a Princess as well. (There isn’t an Evil Queen, though I don’t exclude the possibility I may in fact be that person.) Beautiful and Grumpy I don’t see much, and in any case I like and get along with them. Ditto Bashful, Grandma, and Passive-Aggressive. Princess behaves, well, like a princess though she has children old enough to be in university. But she’s a likeable sort and always means well. Pouter is irritating me all to hell; she’s pouting because I, um, spoke harshly to her friend Shouter, who walks around rigidly and inflexibly, like an angry exclamation point.

Shouter is generally tiresome to deal with, to the point where everyone tends to avoid conversation with her — which of  further angers her and makes her even more rigid and inflexible. Also, I don’t exactly like her (though Lord knows I’ve tried) and the feeling is even more reciprocal on her part. Not very constructive, I know, but I’ve concluded that not every relationship needs to be “fixed” — and frankly, this one ain’t worth the time and effort.

All in all, the work is fascinating, but I will be very glad to finish. I am beginning to think I get along better with the cat than I do with most people.

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What else? A few interviews for other, more managerial positions, which in the inimical manner of Acme Regional’s Human Resources Department, have evidently fallen into the Hell of Waiting for an Answer. “Oh,” they say, “we’ll contact you in a few weeks.” I am not sure what machinations HR needs to carry out to spit out an answer, but there it is.

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Death by PowerPoint. I gave my very first PowerPoint presentation to an enthralled group of colleagues on the topic of sepsis, which my employer has discovered to be the worst threat to patient satisfaction metrics since inedible hospital food. (Seriously. One of the reasons given for beating down sepsis rates at Acme Regional is “to increase patient satisfaction.” And here I thought “Not Dying” was sufficient enough.)

This was my presentation, in thirty-three PowerPoint slides:

Sepsis is very bad and many people die from it. We at Acme Regional, in an effort to be accountable and responsive to patient concerns, are determined to crush sepsis like mice under a stampede of rhinoceroses. In history, sepsis was discovered by Louis Pasteur. He was French. Other French people include Charles de Gaulle and Victor Hugo. They died of something else. In conclusion, not all French people die of sepsis. Thank you.

It actually went very well, I didn’t hardly talk about coagulation cascades and endothelial function, and people were very impressed, etc., and asked pertinent questions at the end like they had paid attention. I was pleased. Having sat through approximately a billion PowerPoint presentations in my nursing career, I have come to the conclusion the key for effective presentations involve three simple rules:

1. Less is more.

2. Speak to the slides, not read the slides. (Your audience is literate, right?)

3. Avoid pathophysiology like Yersinia pestis.

Or else, you can can check this out for good measure.

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In Which I Swear, Repeatedly, or, TorontoEmerg Gets Bullied

I write this blog for a number of reasons: my own amusement, to educate, to share various random thoughts, to tell stories, to stimulate discussion on topics important to nursing, to provoke thought beyond the superficial, to challenge assumptions, and lastly, to rant.

Today I am going to rant.

Those of you with delicate sensibilities may want to get out. I am going to use some earthy language. Repeatedly.

So, to begin: I love my colleagues with the generous love I share with my family, but like some of family, they can be gaping assholes.

I’ve been seconded again for more administrivia duties. Since part of what I’m doing will have focus on improving quality of nursing work life, I am very excited and eager to do this. I believe making our work places better for nurses will, in the end, save nursing as a profession.

For this work, I needed to buy some markers. With the manager’s permission I (innocently) ordered a pack of multi-coloured, fine point Sharpies, which with the wholesaler’s discount came to $6.35 (six dollars and thirty-five cents) plus HST, and charged them to the departmental budget.

The markers arrived on my day off.

Then the nattering started, which (from reports) quickly escalated from a simple “why were these markers ordered?” to attacks on my integrity, discussions about my worth as nurse, and lurid suggestions I was dogging it.

From the reaction, you might have thought I was running a child prostitution ring in the Resus Room, and was using departmental petty cash for start-up costs. It was that bad.

One of my colleagues, a woman I previously thought as an ally, was incredibly hostile. “Why” she asked, “couldn’t you buy your own?” Of course, her anger left me slack-jawed and stupid and the correct answer escaped me at the moment: for the same reason I don’t buy my own kidney basins and bath flannels.

Yes, it was bullying, and afterwards, I reflected on the irony that so soon after writing on the subject I should become a victim of it myself.

So, it was hurtful.  But mostly it really, deeply pissed me off. Remember, I’ve been working with some of these nurses for ten years or more.

I know I’m a damn good nurse, and you’re lucky to have me, so fuck off.

I’m working hard to make your lives easier as nurses, so again, fuck off.

And yeah, I know about horizontal violence and the rest of that, but the bottom line: you are responsible for your behaviour. Stop being a high school gossip queen — and for some of you, you’re closer to retirement than your senior prom — and start being a nurse. Because when you undermine me or anyone of your nurse-colleagues, you’re really undermining yourself.

Another colleague, far more sympathetic, suggested that nurses have been doing it to each since Florence was beating the carpets at Scutari, and we are never going to stop acting, collectively, jerks.

I fear she may be right.

So I say again to those nurses who found it fun and interesting to shred my character in a few minutes time: um, fuck off. And fuck you. You aren’t worth my time.

End of rant. Thank you for your attention.

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Hard Choices

I’ve been mulling this over for while.

A little while ago I was seconded for a couple of weeks to do some adminstrative-type duties (some of which will be subjects of future posts) and in the middle of this the manager pulls me aside and says she wants to recommend me — she’ll be on the hiring panel — to do a temporary managerial position doing xyz related to a Ministry of Health project.

The deal is that if I do it, I will probably lose my charge nurse position — which I really like and worked hard to get —  if I return to the staff nursing at the end of the contract. (I won’t lose my union seniority because it’s a temporary contract.)

The general snake pit of management politics at Acme Regional bothers me little. And I have been down this road before. But not as candidate du jour.

However, the job itself sounds very cool and right up my alley, and also slightly out of my comfort zone; further, it may well lead to other possibilities.

I should mention also, because this is not unrelated, that I am thinking seriously about crossing over to the dark side and getting my MScN. Not doing, mind you, but thinking.

Do I make the jump? Yea or nay?

 

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How Hospitals Punish Nurses for Being Sick

I admit it: I’ve gone to work sick when I should have stayed at home. I’ve gone with hacking coughs, sore throats, Fevers Not Yet Diagnosed, and probable gastroenteritis. I’ve gone in with migraines. Once when I was being treated for an I & D’d abscess, I went in with a saline lok, a kind of intravenous access to give me antibiotics. Should have stayed home, I confess, I know better, but there it is.

So I listened attentively to Brian Goldman’s CBC Radio show White Coat, Black Art this week (you can hear it at the link) on health care professionals coming in to work sick. We do it for reasons perhaps not unique to health care: we don’t want to let down the team, there’s no one to replace us, we’re indispensable. He mentions physicians being expected to show up unless dead or nearly so; nurses, when I was a student at least, were inculcated from our first clinical day that calling in sick was tantamont to being a bad nurse.*

However, the consequences of having sick health care professionals are, of course, unique: we tend to infect patients who are already compromised. As bad, or worse, we compromise our judgement: who can think clearly with a temperature of 39.8C, or while having to run to the toilet every ten minutes? Goldman suggests that a massive culture change in hospitals is necessary to let health care workers take sick days as needed. I agree. But it’s not going to happen any time in the near future: hospital administration itself is the biggest obstacle. There are clear choices in creating a culture that gives permission for nurses in particular to take sick time. I don’t believe hospitals have the will to make that cultural shift.

Let me explain: the problem of sick nurses, other health professionals and ancillary staff coming to work — I’m leaving out physicians, because in Ontario hospitals, they aren’t subject to the same scrutiny as nurses — highlights an internal conflict within hospital administration. In an ideal world, Infection Control in all hospitals would dearly like nurses and the rest to stay home if they’re sick. Patient safety, after all comes first. In the real world, however, hospital Human Resources departments do not consider infection control as a priority. Human Resources views sick time as a controllable cost, and frankly, sick nurses a problem to be managed.

It’s true in general that nurses take higher than average rates of sick time. The reasons for this are complex: we are, after all, exposed to infection on a daily basis, the nature of our work is highly stressful (which in of itself has health consequences), and sick time is an indicator of nursing morale which in many hospitals is quite poor. The job of human resources is to provide strong disincentives to nurses (and others) calling in sick. They d0 this in a couple of ways. In Ontario, hospitals cut sick pay for nurses by up to a third, depending on seniority. If you’re a sole-wage earner living paycheque to paycheque, it’s a substantial amount. Pragmatically speaking, if it’s between feeding your kids, and coming in sick, even if you are a conscientious nurse, guess which will win.

Further, nurses must cope with attendance management programs. In Ontario, and I know this is true in many American hospitals, nurses are subject to punishment if they take as few as three sick days, and made (with union acquiescence) to attend humiliating, disciplinary “attendance-management” meetings. For their part, hospital management and the union — the Ontario Nurses Association — will vehemently deny the attendance management process is disciplinary in nature. Personally, I have never been subject to attendance management. But I have seen nurses leave these meetings distressed to the point of tears, and I know of one nurse who left her position and the hospital because of Human Resource harassment. It’s discipline by other means and it’s a strong deterrent to taking sick leave. I’ve come in sick myself knowing I was close to the threshold of being put on “The Program.”

A conversation I had a few months ago with the Infection Control Nurse illustrates quite nicely this tension between the conflicting goals of Infection Control and Human Resources. The context was a mini-outbreak of gastroenteritis; three nurses were off sick. The Infection Control Nurse got wind of this outbreak, and wanted to ensure the nurses stayed home for 48 hours after the last symptoms, as per hospital policy. She wanted names, which I refused because of confidentiality.  She then wanted me to call the nurses. I refused again. I knew at least one of them was already in some difficulty with the attendance management program, and I was unsure about the rest.

“Well,” she said. “Let me call them.”

No, I said. I explained to her how Human Resources will punish the nurses for following hospital policy.

“Oh,” she said. “That’s a human resources issue, not an infection control issue.”

Actually, I thought, if you have an otherwise diligent, handwashing-fanatical nurse like me resisting infection control directives, human resource policy is an infection control issue.

In the end, hospitals must choose between trying (and mostly, I think, failing) to control sick time costs and making infection control truly a priority. It’s no good telling nurses to stay home if they are sick, only to turn around and punishing them for fulfilling what is really a professional obligation. Half-measures, like telling nurses to mask for their 12-hour shift, or to be “extra-diligent” in handwashing are impossible to enforce. Maybe some innovation is needed on how we look at sick time. One U.S. hospital I know of recognizes only 2-3% of employees abuse sick time, and assigns twelve days a year for “personal use,” no questions asked, after which HR begins to apply the screws. Nurses who leave part or all the personal days untouched get a payout of three of those days on a pro-rated basis. A change like that would indeed entail a massive culture shift. Present practice does not truly address infection control issues raised by health care professionals working sick, and sends conflicting messages to nurses. Either infection control is a priority for hospitals, or it isn’t. Which is it?

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*I’d be interested hearing from new grads whether this is still true.

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Reflections on Being Charge Nurse

It’s been about two months since I started in the permanent charge nurse Clinical Care Leader position, and I have to tell you, it ain’t what I expected. I’m not complaining. But this might be the hardest, most challenging job I ever had, and that includes the hot summer I worked in the kitchen of a Greek restaurant whose owner pinched my bum. Some reflections:

1. You can’t be everyone’s friend. A cliché that’s actually, really true. The people you thought were on your side start to look at you sidewise,and the people who didn’t much care one way or the other really begin to hate you. Let’s face it: sometimes you make decisions that piss people off.

2. You can’t please everyone. Corollary to the above. No matter what you do, or how carefully you consider each decision, there will be someone, somewhere second-guessing you, and then bitching loudly about how they would have done things differently.

3. The faint of heart, thinned skin and unconfident need not apply. Probably true of emerg nurses in general, but more so for charge nurses. Having the hide and temperament of a rutting rhinoceros is a definite prerequisite. After being called racist and being told to eff-off in the span of a week, I feel like I need body armour.

4. Cool not hot. When the place is falling down, two VSA’s* have arrived on the doorstep simultaneously while an indrawing, tripoding† three year-old is at the Triage desk, Plastics is having a tantrum because there’s no more 4.0 Plain Gut left in the department, and Weanus is walking towards you with look on his face that would frighten children, a charge nurse running around screaming like the Four Horsemen of the Apocalypse have just galloped through the ambulance is not helpful. Keep it cool, because

5. All disasters pass. When the place is falling down, the effect is temporary. Really. Beds upstairs will appear, Weanus will go off muttering, the VSAs will die or survive — in short, all crises are temporary, by definition.

Except when they’re not.

6. I work with some amazing nurses and some distinctly nasty personalities. Some times they are the same people. I used to think this was a contradiction. Now I am not so sure.

7. Sick calls are highest Friday nights and Monday mornings. Except on statutory holidays, when for some reason we are always fully staffed. Don’t think I don’t notice.

8. Physicians start treating you with respect. I have specialists, who in my ten years at Acme Regional, have never once spoken to me directly, suddenly asking about my summer holiday plans and buying me coffee. It’s weird and creepy, but also a pretty sad commentary on perceptions of power in large hospitals.

9. Your colleagues have no idea what you do. I mean, they could probably describe it generally, but somehow think it mostly involves sitting around and directing traffic. The short list of what I do? Let’s see: bed allocation and patient flow in the ED, staffing, staff assignments and scheduling, supply ordering, allocation of beds for admitted patient on the floor, dealing with angry/complaining/grieving patients/nurses/physicians, being the liaison with other floors and departments on a day-to-day basis, helping to carry out new policies and procedures and ensuring compliance, mentoring and role-modelling, attending various committee meetings important to the emergency department. . .

Maybe I should develop a list of core competencies.

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* See Glossary

† I.e. in respiratory distress.

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Craptacular

The bad news is I had such a craptacularly (as Bart Simpson would say) awful night I’m nearly incoherent.  One of the many, many highlights was having the wife (or symbolic, Oedipal mother, so enabling was her behaviour) scream for a warm blanket for her “cold” and “shivering”, drunken husband while I was trying to give IV diltiazem to an atrial fibber with a heart rate of 175, more or less.

I actually weighed this in mind, amazingly enough —

warm blanket?

diltiazem?

warm blanket?

diltiazem?

warm blanket?

diltiazem?

— for about 1/100, 000 of a second before turning my back and drawing up the diltiazem.

The good news for you, dear reader, is that I have material for several posts.

But first for me, a Gravol and two Tylenol 3, and bed.

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Can We Kill Nurses Week? Please?

Another year and another dreadful Nurses Week approaches. You know, that time of year when nurses are supposed to get all Glad and Bursting with Happiness at our chosen Profession — sort of like Christmas for nurses, except far less cheerful and filled with people you wouldn’t invite into your front hallway. But at the level of employment, anyway, Nurses Week has devolved into a vehicle for management to show its respect and gratitude for its nursing staff. The trouble is, nursing management is generally clueless about how to thank nurses. My jaw literally fell open when I had one usually savvy manager tell me, in all seriousness, that Acme Regional showed respect and thanks for its nurses by paying us, when I thought, incredibly, they paid us because they wanted us to show up for work. Silly me. Obviously there’s a problem here.

Even without seeing a calendar of events I know

  • the schedule itself will be called “Nurses’ Week Events and Festivities,” which implies, at the very least, a joyful celebration of accomplishment, excellence and maybe even fireworks.
  • there will be a “special guest speaker” at some point during the week, who will be scheduled to lecture at a time nearly impossible for front-line nurses to realistically attend, even if they got permission to leave the floor for an hour, and on a topic having absolutely no relevance to their practice — but managers will enthuse over.
  • the local union will put a dinner at Al’s Fish Fry Factory and Spaghettoria clear across the city which no one will attend except ten stewards and a confused respiratory therapist.
  • the Auxillary will cart around free coffee for the nurses (one only please!) on either Monday morning or Wednesday afternoon. In a small-size  styrofoam cup.
  • the hospital president will write an open letter which will contain each of  the phrases “compassionate and caring”, “management team” and “together we will succeed”.
  • a gift basket donated by a local business will be raffled, mostly because it’s a leftover from the Silent Auction fundraiser, and therefore “free”.
  • various managerial types will wander aimlessly through the hospital giving out warm fuzzies.
  • there will be some sort of  “gift bag” — though I use the term in its loosest sense. One year we got (I kid you not!) a homemade bookmark and a 15 cc bottle of hand lotion. The bookmarks were created by the Volunteer Auxiliary as “their gift to nurses”.  Last year we got pens donated by a cut-rate, generic pharmaceutical company, which stopped working in ten minutes, and a little laminated card outlining emergency procedures. (“In case of bomb threat, nurses will search their units for suspicious packages.” Like gift bags from management?)

I would like to think management believes sincerely believes Nurses Week is a great morale booster. I do understand there are budget constraints — though in a world of catered lunches and embiggened CEO salaries this argument is harder to make. But it’s hard to imagine a timetable of events more dispiriting to the practice of nursing, more meaningless and insulting to nurses, or more transparently self-serving for management. It sends the unmistakable signal of exactly how much hospital administrations value their nurses — and if your schedule of events resembles mine, it isn’t much. And the funny thing is, it’s been nearly the same story in every place I’ve worked. We’re served turds for Nurses Week and told they’re gold nuggets.

I don’t need this kind damage to my self esteem. It’s time to kill Nurses Week. Drive a stake through its cynical heart. Nurses deserve much better.

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