Posts Tagged Nurse
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.
Dinner last night with an old friend who toils in the mines of Labour and Delivery. She has worked there for four years. She told me of an incident not too long ago working the night shift, faced with a post-partum patient who was bleeding, hypotensive, and tachycardic, in short, showing all the signs of going into hypovolemic shock. She was running around, starting IV lines on flat veins and hanging blood products. Packed red cells. Platelets. Cryoprecipitate. And by-the-by, saline by the bucketful. She called for help from her colleagues. Apart from this patient and another who was walking the halls a few hours from delivery, it was a slow night.
Of course, you know the end to this story, don’t you?
No one came.
No one even popped their head in the doorway to ask, “Is everything okay?”
All of them were at the nursing station, playing Draw Something on their phones, watching the season finale of Grey’s Anatomy, what have you. Too busy to help a drowning colleague with a shocky patient.
My friend went to her educator and her manager. They shrugged it off. No biggie, they said. Clearly my friend had things under control. “The patient lived, didn’t she?” they said. And then: “Maybe you need to improve your organizational skills to handle critically ill patients.”
This last to a 50-something woman who has been nursing 25-plus years, almost all of it in critical care settings.
For my friend, this incident may well be the last straw. She is definitely leaving L & D. Why would she want to stay? The workplace culture on this unit is awful. She feels alone and isolated when going into work. She can’t trust her colleagues. “Why,” she asks, “would anyone want to work there? There is no teamwork. No solidarity. Nurses backstab each other at the first opportunity.”
The only question remaining is whether my friend will leave nursing altogether and take her 25-plus years of experience with her, which included not only the knowledge to provide expert care to patients, but the potential to share that expertise in mentoring and nurturing new nurses. She’s uncertain what she would otherwise do, but leaning towards abandoning the profession which has shaped her adult life. She only needs an out — which she hasn’t found yet. She is that disgusted.
You might tell me that stories like this are unusual and not representative of nursing. Unfortunately, we all know better. So in the end, I don’t blame my friend for wanting to leave. I would do the same.
So what would be your response?
UPDATE: Some comments from Twitter:
The second to last tweet from @NorthernMurse is probably the relevant question, don’t you think?
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Guest Post, Nursing Naval Gazing on Tuesday 22 May 2012
by Amanda Trujillo
If the newer generations of nurses out there are more confused than ever about their roles in healthcare — they should be. I’m one of the newer generations of nurses and I — AM — CONFUSED. Seriously. Think about it. We are taught all of the idyllic, pretty things every good and prudent
nurse should know and should do whilst caring for patients. The Nurses Code of Ethics is drilled into our heads during nursing school, nursing care plans are celebrated (by our professors of course), and we are championed as the “future” and “promise” of nursing. The beautiful glowing white walls of academia ushers us out of the proverbial nursing nest with a maternal pat on the head, a gentle push, and into the place were supposed to actually do all the stuff were taught and licensed to do, and be who they taught us to be.
You’ve all heard it, I’m sure. “Get out there and make a difference! Change the profession for the next generation! Be the example! Implement policy! Be advocates for your colleagues and your patients!” Ummmm. Yeah. Nurses should act as advocates for not just their patients but for their profession. That being said, let’s take a look at what threatens to unravel the foundational fabric of who we are as nurses and what we do that sets us apart from all other healthcare disciplines.
1. Corporate Nursing. “We know what nursing is and what nurses do.” However, the moment you walk into the doors of any hospital, the nurse — the persona, and everything else — is redefined according to the wants and expectations and interests of the organization we work for. Nursing, as a discipline, as a science, is redefined. You are who your employer wants and expects you to be. Period. Your own nursing style or “way” of nursing? Leave it at the door, and step into the predefined mold thank you very much. Advanced education? Yeah, that’s great, but you aren’t actually supposed to use it. That MSN is supposed to look good after your name on the plaque that lists all the Masters prepared nurses on the unit you work within. A point of pride that all patients are supposed to gawk at and be impressed by when they walk into the entry way of the nursing unit. I tried using it; I tried to contribute—nope. We just want the letters from you, that’s all.
2. Teeny, tiny amount of autonomy. I mean, come on people. We still have to get orders to ambulate our patients two to three times daily after surgery, to get an incentive spirometer, to initiate pre and post-op teaching, and even to monitor ins and outs every four hours. Every state has a different nurse practice act, and there is no set regulation as to what nurses can and cannot do across the United States. Every state defines Nurses and their practice and what they can do differently. Take a group of 5 doctors—and chances are each one of them don’t even have a good understanding of what nurses are and what they do and their role. Interdisciplinary Models of Care are not the standard yet, so this inhibits a productive and working knowledge of what each provider does.
3. Disregard for Care Plans. This is a big one for me. I recently read a couple of articles that, for the most part, said care plans should just die and go by the wayside because they are useless.
4. A fractured profession. We have so many specialties that we still have failed to come together in a unified manner to advocate together for our profession and for the vital role we play in the lives of our patients, evidence based practice, theory development and application, and policy making. The result? Thousands of different visions from thousands of different nurses about what our profession “should be” and “should do.”
5. Silencing of our voices. We now have to choose between our own career survival, or own livelihoods, professional reputations, and paychecks—and speaking up in the best interests of our patients. Many a nurse has experienced this tragic conundrum, and the consequences are well documented if you log into your university libraries and do a good literature review on the topic. So, which will it be? Your pay check or your patient’s life? Well, now, that depends—can you like yourself when you go to sleep at night or when you wake up the next morning. The choice will be different for all of us.
6. Too many initiatives!!!! There are so many initiatives out there that it truly is like ‘herding cats’ to get everyone on the same page about what needs to bedone to improve, advance, and grow our profession.
What I feel needs to be done is simply this: get back to basics. All the initiatives are great. The pretty, flowery, shiny, idealistic profession they propose is in theory—just that. It seems like every time we turn around there is another nursing initiative being introduced. In fact, there are so many, we all seem to have thrown up our stethoscopes in exasperation while uttering “Whatever.” The RWJF, the NIH, AACN, the National League for Nursing, Johnson and Johnson, the Institute of Medicine and all the other organizations that produce the massive documents proposing their positions on where nursing should be by the year “such and such” need to set aside “Candyland” and get back to the drawing board.
How? Perform a learning assessment and care plan on the profession. TALK TO THE NURSES AT THE BEDSIDE—these are the stakeholders that have to carry out all the grandiose changes. ASK nurses what would motivate them to carry out change and what they need or want to learn to carry out the change. Perform a force field analysis to illustrate whether there is a greater push for or against change and where a balance can be achieved to promote success. What do nurses consider an incentive to participate in the change process? What is their currency?
Here is a good example of what happens when big organizations try to make even bigger changes sans discussion with their staff members, which is to say, their stakeholders. At one hospital I worked at the Transforming Care At The Bedside Initiative was being “enforced” as a means to improve patient satisfaction scores. I say the word “enforced” because we nurses weren’t asked about how we felt about it, we weren’t “completely” educated about what TCAB was, why we should be interested in it, or why we should participate in it. participation was an expectation and people were “assigned” to do parts of the initiative. No communication took place between management and staff about how they felt about the change process or the new “tests of change” they were being expected to participate in. So, it was not a big surprise to see my coworkers increasingly annoyed when they were being presented with “more steps” in their workday, or “more papers” to fill out or “scripts” taped to their computer monitors directing what they were to say to their patients. It was also not surprising to see that few or no staff members were attending the TCAB meetings to provide input and feedback.
Having gotten my Masters Degree I quickly realized what was missing was a well-planned approach to the change process. A crucial step within the change process is involving every person that could possibly be involved in that change: polling people, studying your stakeholders and what their motivations are, illustrating what is ‘in it for them’ should they take part. Failing to study all of your stakeholders and ask for feedback prior to initiating change is simply wasting a lot of time and yelling through a megaphone at an empty nursing station. I did some further research into the TCAB Initiative by immersing myself in the RWJF website for a couple of weeks.
After doing so, I discovered that our organization was not implementing TCAB as it was meant to be implemented. The organization was taking bits and pieces of the initiative and implementing them. The focus of the initiative — promoting happy nurses to promote happy satisfied patients — was not the managerial focus, as it should have been. It was strictly designed for patients, completely overstepping the spirit of the TCAB initiative as it was meant to be implemented. Lastly, the TCAB initiative was designed to be an interdisciplinary effort. The way it was being pushed at the organization I was at, the focus was just on nurses. I put together a white paper and power point and submitted them to my manager hoping it would help to get the project on track. I was promptly shut down with an annoyed response that my work looked plagiarized. (This is what an MSN on a nursing floor gets you)
So, managers, here are some lessons learned. If you want to make change on a large scale you must invest the time, no matter how long or how involved the effort, to study the people who have to carry out the work. Find out their goals, wishes, motivations, concerns, what makes them happy, angry, and frustrated. Find out what their knowledge base is and what must be learned to carry out the major initiative. Ask for their input. Discover who your “downers” are, why they are resistant to change, and how can you get them on board. It’s called “buy in.”
Lastly, harvest your talent. Take a fresh look at who your voices and cheerleaders are on the unit and give them “room to bloom where they are planted.” This is how and where you become a transformational leader instead of a leader who suppresses the creativity and potential of your nursing staff. One note: if you are going to implement something huge like the RWJF TCAB Initiative, don’t just take pieces of it and throw together your own version and expect it to work.
This, in my opinion, is what all of the large nursing organizations who want to transform healthcare need to do. Round everybody up for a week-long conference, every stakeholder — not just administration and management figures or politicians either. The real people: the bedside nurses, pharmacists, lab workers, patients, doctors, PA’s, housekeepers and so on. Paint the closest picture you can get to a collective vision everyone seems to share. Then, figure out how to get there, one step at a time.
All the big goals are great.I love the visions of where the RWJF and the IOM and the AACN see our profession, healthcare, and nursing education headed. But the visions are a problem too. There are too many ideas, initiatives, and too many people “other than bedside nurses” generating them. Our profession is fractured enough. It is not feasible, nor is it realistic, to expect every wonderful idea and vision to be carried to fruition when there is currently a longstanding lack of unity and disarray within nursing.
So, for the time being, let’s set aside the huge mountain of ideas and initiatives and take a deep breath. Now, start over with the A-B-C’s: Airway, Breathing, Circulation. Set the sights on resuscitating the profession of nursing first, before we attempt to heal the ailing healthcare system and the world. Take it back to the old school, and do the assessment first. Then, make a plan: implement it, evaluate it, and do it all over again until we get nursing back on track with a unified focus. Only THEN can we climb the mountains set in front of us by the RWJF or the IOM or the NIH. We cannot build castles without a strong foundation of earth below it.
By the way . . . Did anyone notice how often I used the word “initiative?”
Amanda blogs at NurseInterupted. This is a slightly modified version of a post which originally appeared on her blog.
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.
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.
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?
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Uncategorized, Warm Fuzzies on Friday 20 April 2012
Some real nurse love — and incidentally reminding us why we have the most tremendous profession in the world and how we each day make a powerful difference in the lives of our patients. Via the blog The Spohrs are Multiplying, Mike Spohr writes about the day his child died:
On the horrible day that Maddie passed there was a nurse who stayed by Heather’s side the whole time, and I am so thankful for her kindness to my wife. There was a nurse that mattered to me too that night, though she didn’t stay by my side, bring me a glass of water, or even say a word to me. In fact, I don’t think I saw her until the last few seconds I walked out of the PICU, but she made a difference nonetheless.
You see, that day my life shattered. I watched my daughter die in front of me, and it was an experience so horrific that even now it seems almost surreal, like, “Did that actually happen? To me and family?” But it did, and one of the things I remember most about it was how the key medical personnel there didn’t make me feel like they found Maddie to be beautiful and strong or amazing and a gift. The lead doctor, for example, was under a great deal of stress, but the way he pronounced her dead was not right. It was more like a referee calling the end to a heavyweight fight than the end to a beautiful child’s life. Then, as we held our dead child in our arms and kissed her goodbye, doctors stood behind the curtain discussing the specifics of what had happened with about as much feeling as mechanics discussing a broken down car.
It was only as I left the PICU that I felt humanity from the medical staff. There, sitting on a chair with a single tear rolling down her cheek, was my nurse. Her tear told me that she cared. About Heather, about me, and most importantly, about my beautiful Madeline.
That’s what nurses do that is so important. In addition to all of their medical expertise, they bring a human element to the cold, sterile world of a hospital. Doctors do great things, but have a heavy case load that means they can only visit each patient briefly each day, but the nurses will hold your hand – figuratively or literally – and remind you that you are not alone, and that your life is valued even if it can’t be saved.
A good and valuable antidote to the river of treacly pronouncements and saccharine encomiums we are about to receive from our employers, nursing leaders and other power centres in the nursophere in anticipation of Nurses’ Week. Worth about a million of ’em, I think.
Should nurses give up their chairs for physicians? A nursing professor named Susan Kieffer writing at NurseTogether.com thinks so:
If you have been a nurse for any length of time, you know how precious the seats at the nurses’ station really are. These seats are a rare commodity; one to be cherished and guarded once you snag one. It is also true that the coveted chair can be very revealing regarding the professionalism of the person occupying it.
Uh-huh. Kieffer goes on:
I will pose to you a question that I recently asked a class of students: registered nurses who are taking their first course in their journey to their bachelor’s degree and are studying the art of professional nursing. Many of them have been practicing nurses for 20 years or more. Here is my question to them: “As a professional courtesy, would you willingly and gladly give up your chair at the nurses’ station to a… to a… wait for it… a doctor?”
Kieffer goes on to argue that nurses are bigger than their ownership of their chairs by a mile. In other words, we’re better than those nasty physicians, even when they are nasty to us. I call Kieffer’s argument The Chair Strategy for Recalcitrant Physicians:
So, here is the point that I wanted to make with my students and will do so here as well: I believe that giving up that chair to the doctor shows the utmost in professionalism, courtesy, and confidence.
Can we not be confident enough in our abilities and our practices that we do not feel like we have to prove ourselves by remaining seated while the physician stands? If a nurse gives up his or her chair at the nursing station to a physician, maybe even the very doctor who was disrespectful a few minutes ago, I believe that it shows that the nurse’s professionalism is a notch above the norm. It’s like taking the high road in the midst of mistreatment. Such professionalism could go a very long way in increasing the respect given to us in the health care community. Who knows… maybe our example will eventually lead to a physician offering his or her chair to US!
I know many of you are now rolling around on the floor in a display of unrestrained mirth. But stop it. Right now. This is a serious question, posed by one of our nursing
betters leaders. And I will offer a serious and considered response.
My short answer is not only No, but Hell, No.
Two reasons: first, though I do have a streak of unreconstructed idealism a mile wide, I am not so naïve to believe that the Chair Strategy will ever cause physicians to respect us more. There is not enough Pollyanna in the world to make this possible. It isn’t as though physicians spend their sleepless nights agonizing over the burning question of Disrespectful Nurses. In any case, why (insert eye-rolling here) are we obsessing over what physicians think of nurses anyway?
And the Chair Strategy as the cure for bullying physicians? Please. Good physicians treat nurses professionally, with dignity and respect. Their opposite numbers are only going to be encouraged by subservience. Such physicians need to be called on their behaviour by assertive and confident nurses and if necessary reported to higher authorities, not coddled and enabled to be bullies.
My second reason has to do with the paternalism implicit in Kieffer’s article. I am not old enough to remember those halcyon days when nurses rose to their feet when the physician (in all of his god-like powers) entered the nurses’ station — no nurse would ever sit in the presence of a physician, God forbid — and when the charge nurse followed him on rounds, to open the door to ward rooms and take orders. But I am old enough to to have been educated by nurses who did remember those days, and their memories were not fond. The point of all the sitting and not sitting, giving up of chairs, and attending the physician like a pug dog follows a child was not “professional courtesy,” but a reminder of the power relationship between physician and nurse, and the place of nurses and nursing in the hospital hierarchy.
Kieffer misses this point. She ignores the obvious symbolism, that who gets to sit and who doesn’t speaks directly to hierarchy and deference to superior authority. Nurses who robotically and without thought give up their chairs are implicitly saying, “Here, doctor, take my seat, because what I am doing can hardly compare to the importance of your mighty role in the provision of health care.”
Let’s put this in practical terms: if I am sitting in the nurses station, I am charting or otherwise doing something requiring the convenience of seating. I am not going to offer up my chair to a physician qua physician for her or his convenience. The reason for this is simple: I have work to do. Which in the scheme of things, is as about as important for overall patient care as any physician’s. If you believe what you do is somehow of less importance or insignificant compared to a physician’s, by all means give up your seat. (Neck rubs for said physician are optional.) If you believe your time and convenience is at least as important of the physician’s, kindly yet firmly direct them to the consultants’ room — or any other alternate seating.
I will grant Kieffer this: she is right on the larger issue of professionalism. If nurses are sitting around texting or Tweeting or drinking coffee while looking over catalogues, by all means move if a seat is required. But that’s just common sense and courtesy, and not restricted for physicians alone.
One last point: does anyone know why, exactly, we are talking about nurses giving up their chairs for physicians, in this the year of God’s grace, 2012? Does anyone actually think Kieffer is correct?
Gob-smacklingly stupid or hip advertising? I’m leaning towards the former. Via CBC:
A Stockholm hospital that published an online ad looking to fill a summer position with a nurse who is “TV-series hot” says it was “written to catch people’s attention.”
“We want people to be curious and have a little imagination,” said Elisabeth Gauffin, head nurse at Stockholm South General Hospital (Södersjukhuset) to the Metro newspaper.
The ad read, in Swedish:
“You will be motivated, professional, and have a sense of humour. And of course, you will be TV-series hot or a Söder hipster. Throw in a nurse’s education and you are welcome to seek a summer job at Södersjukhuset’s emergency department.”
(“Söder” literally means “south,” but here refers to Södermalm, a fashionable district in Stockholm. Think “Soho.”)
The hospital’s nursing manager said the phrasing wasn’t meant to exclude anyone based on looks.
I (sort of) get what the hospital was trying to do. Readers may have noticed I’m not without a sense of humour. But I’m not sure the “And of course” phrasing of the ad effectively signals the intended irony. It’s a little pathetic the hospital needs to rely on a tired old cliché to recruit nurses. Ultimately, I think, the ad trivializes what nurses actually do in Emergency departments, and reinforces public perceptions and stereotypes. As a well-seasoned RN, I would be somewhat disinclined to work there. But maybe it’s all lost in translation, and the ad is deliciously funny in the original Swedish.
Incidentally, for the record, I am not “TV series hot.” On the other hand, I know to work the buttons on a defibrillator.
[Thanks to my friend Leigh for sending this along to me. Her comment: “Laugh or cry?? Mostly exasperation I think. Add more horror that the survey results show that people think this is appropriate!”]
News flash! From Fierce Medical News, here’s the shocking headline:
Docs, nurses miscommunicate on respect, job role
When you guys pick yourselves off the floor from laughing, here’s the money quote:
In particular, the survey found differing views of how doctors treat nurses. According to 42 percent of nurse leaders, physician abuse or disrespect of nurses was common, whereas only 13 percent of physician leaders said it was common. Fifty-eight percent of nurse leaders considered disrespect for nurses uncommon, while 88 percent of physician leaders said it was uncommon at their healthcare organizations.
“I do believe nurses and physicians are on two different pages when it comes to communication,” Pam Kadlick, vice president of patient care and chief nursing officer for Ohio’s Mercy St. Anne Hospital, said in a HealthLeaders Media article. “Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times.”
But most physicians don’t consider such behavior to be disrespectful, she noted.
You’re telling me abuse of nurses is all about physicians being insensitive, maybe, and nurses having too many hurt fee-fees? Really? And nurses are supposed to be surprised that physicians “don’t consider such behavior to be disrespectful?”
Why does this sound like a ’80s sitcom?
Why does this sound like this report is trying to validate abusive physician behaviour?
You can only shake your head. And you just know, somewhere, in a darkened office maybe, in an obscure corner of a mega health care corporation, a manager is reading this report and exclaiming, “I knew nurses were to blame!”
I will very happily concede abusive behaviour of all kinds has declined markedly in my own time as a nurse, though I will say I work in an institution that enforces a zero tolerance policy against abusive behaviour. Moreover, the physicians I work with, shoulder to shoulder, are lovely and professional, and there is a true sense of collaboration. This makes for excellent patient care.
However, by no means is this true everywhere. So let’s not pretend the brow-beating, the mocking, the chart-throwing, the patronizing — to be blunt, treating nurses like you wouldn’t treat your mother, daughter, wife, bank clerk, Wal-Mart greeter, housekeeper, or dog — still doesn’t go on. Denial will never fix the problem, either from physicians — or nurses.
By David F. Baehren, M.D.
[. . .]
We usually look afar for heroes and role models, and in doing so overlook a group of professionals who live and work in our midst: nurses.
And not just any kind of nurse: the emergency nurse. There are plenty of people involved in emergency care, and no emergency department could function without all of these people working as a team. But it is the emergency nurse who shoulders the weight of patient care. Without these modern-day heroes, individually and collectively we would be in quite a pinch.
It is the emergency nurse who cares for the critical heart failure patient until the intensive care unit is “ready” to accept the patient. The productivity of the emergency nurse expands gracefully to accommodate the endless flow of patients while the rest of the hospital “can’t take report.” Many of our patients arrive “unwashed.” It is the emergency nurse who delivers them “washed and folded.” To prepare for admission a patient with a hip fracture who lay in stool for a day requires an immense amount of care–and caring.
Few nurses outside of the emergency department deal with patients who are as cantankerous, uncooperative, and violent. These nurses must deal with patients who are in their worst physical and emotional state. We all know it is a stressful time for patients and family, and we all know who the wheelbarrow is that the shovel dumps into.
For the most part, the nurses expect some of this and carry on in good humor. There are times, however, when the patience of a saint is required.
[And so on and so forth. Read the rest here. I couldn’t find a link to original article. Sorry.]
Then I thought about it. The nurse-as-saint-and/or-angel meme is quite strong in this piece, and is something that needs to be retired quickly. And why do nurses look to other professionals for validation?
Or am I being churlish?