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.

Scripting Nurses is Bad for Patient Care

This might be a new low in nursing management. Instead of actually providing caring, empathy and compassion, some hospitals would like nurses to provide a simulacrum of caring, empathy and compassion, believing patients are stupid enough not to tell the difference:

Nurses unions say an increasing number of hospitals nationwide are asking nurses to adhere to standard scripts when talking to patients, down to how often they use a patient’s name (at least three times per shift)

At several Massachusetts hospitals, nurses have been given laminated cards to hang around their necks with the words they should utter at the end of every visit: “Is there anything else I can do for you before I leave? I have the time while I am here in your room.’’

These particular words, consultants say, are important because of research showing that patients are more satisfied with their care when they believe nurses made time for them. [Emphasis mine.]

This is called “scripting.”  It’s the newest shiny object for nurse managers. The underlying philosophy is that it doesn’t really matter if the nurse in reality establishes a therapeutic relationship, administers a medication properly and safely, completes a thorough and accurate assessment, or does all the myriad (and out-of-sight) procedures and processes necessary to ensure a successful and healing visit. All of that falls by the wayside: what’s most important and valuable is that the patient believes they got good care.

Of course, there is a fairly large gap between reality and belief. When I worked in the United States, my employer was exceedingly concerned with customer relations (I use the phrase advisedly), and regularly called nurses on the carpet for (allegedly) dissing patients. I personally was the recipient of a patient complaint in this regard: she believed I was missing in action for her entire visit. Fortunately I had charted extensively and nearly hourly because she was also receiving some high doses of narcotics and spent most of her visit sleeping. My care, in fact, and I will blow my own horn here, was exemplary. But you see the point. There is no such thing as the completely satisfied patient. It is a myth. The capacity for patients being satisfied on every aspect of their care is nearly infinite. Unfortunately, our capacity to make patients satisfied in all things is rather constrained. Patient care is complicated. It’s impossible to account for every contingency. Furthermore, patients sometimes equate nursing care to hotel room service. Sadly, we aren’t bellhops or waitresses. Trying to achieve patient satisfaction in each and every case  is a ultimately a losing game.

In any case, the value of scripting nurses, at least in the Emergency department setting, might be limited. One study indicates patient satisfaction scores remained constant pre-and-post introduction of scripts in an ED. This suggests to me, anyway, that scripting is just another in a long series of quick fixes for a problem which is actually hides the real elephant in the room: the link between nurse working conditions and job satisfaction, and patient mortality, morbidity and overall satisfaction. Nurse Keith at Digital Doorways excellently discusses this in blog post on the same subject. I won’t rehearse the argument at length, which basically boils down to “happy nurses make for happy patients.

So in the end, do you think treating nurses like idiots would increase or decrease job satisfaction? And how do you think that affects patient care?

[Update: corrections in formatting made. I sometimes forget WYSIWYG blogging isn’t always WYSIWYG.]

Nursing Makes Nurses Less Empathetic

Irony alert! The best way to decrease empathy in nurses, apparently, is to actually practice nursing. A new study of nursing students found that

as students gained more clinical exposure, they demonstrated a much greater decline in empathy scores over the year than did those with limited clinical experience during that year. This finding extended to students with previous work experiences in the clinical setting, who also evidenced declines in empathy of practical importance. . .

The study indicates the usual suspects in this decline of empathy: lack of time to empathetically interact with patients, lack of support, lack of role modelling, focus on the technical aspects of nursing and so on. It concludes:  “[U]ntil the art of nursing is recognized as a necessary criterion for successful completion of coursework and as important as passing an exam, students will likely continue to demonstrate behaviors that make them good technicians but not necessarily very good nurses.”

Ouch.

But I’m not very surprised. I was speaking to a friend the other day who is a clinical instructor for a certain university-based nursing program in Toronto. She told me of the open and enormous contempt the academic instructors at this university have for the clinical instructors (the majority of whom are bedside nurses as well) and by extension, for bedside nursing in general. (This isn’t the first time I have heard this, and I have experienced this myself when I was a clinical instructor.) It isn’t a large leap to suggest what we esteem in bedside nursing, i.e. empathy and compassion, are devalued in the same way, and that negative attitudes are passed on  to students.

The rot, it seems, begins early. I would be interested to know the experience of other clinical instructors, or new graduates. Or am I just talking through my hat?

 

Do Nurses Have the Courage to Stop Bullies?

Hands up, nurse colleagues, if you recognize this story: bright young new grad lands dream job in sophisticated critical care unit by dint of hard work, persistence and perseverance, finds said unit is actually populated by orcs, trolls and toads. NurseXY provides the unpleasant details:

It was nice while it lasted, but the honeymoon is over. The true colors of my coworkers are starting to show through.

[SNIP — but NurseXY’s post continues with a heart-warming tale of nurses acting their very best. Go read the whole thing.]

I’m so very tired of hearing, [he goes on] “You have to be careful how you approach so and so about that.”

Why can’t I openly and clearly communicate my patient’s needs to those responsible for assisting me in caring for them? I am so tired of having to slink up to various people from docs to support staff like a helpless, hapless junior high damsel in distress to get what my patient needs. Too many egos to stroke. I demand respectfully request you grow the #@$) up.

And it’s only been 3 1/2 months!!!

I’ve written about the phenomenon of nurses behaving badly to their colleagues so often it’s tiresome. And sadly, I think, we’re all complicit in permitting bullying behaviour amongst ourselves, whether we are experienced nurses “breaking in” new staff, managers who avoid the issue, or tacitly permit it as a management technique (and this is far commoner than you might think), or educators who think abuse is the best way to train new nurses. It’s so ugly and so pervasive I sometimes despair for my profession.

RNnnnrGrl, after reading NurseXY’s post, vents on her blog at some length about the special hell of working with “seasoned nurses.” She’s on the mark, but maybe not in the way she thinks. While I don’t believe for a minute that bullying nurses make up more than a tiny fragment of our profession, how many times have we older nurses stood by silent while we let a bully tear into a nurse? When we passively let them stand unchallenged, it’s effectively the same as being bullies ourselves. So what to do? An excellent article at Medscape provides some practical responses to bullying:

Murray suggests that nurses should take a collaborative approach to bullying; nurses should “look out for each other,” and support victims of bullying during and following an episode, including reporting the incident. Victims are encouraged to document incidents of bullying, including date, time, site of occurrence, and witnesses.

Dellasega has this advice for nurses who witness an episode of bullying: “Intervene quickly to prevent minor conflicts from escalating.” Often, she continues, “a misperception or false assumption triggers behavior that spins out of control.” Because bystanders usually outnumber bullies and victims, they can act together to alter the situation’s dynamic and avert a bullying incident. “You can intervene on behalf of a coworker who is being bullied by asking her to help you with a task in another location, speaking up on her behalf, or simply standing beside her.” Dellasega also cautions nurses about participating in gossiping, which is also a form of bullying. [Emphasis mine]

I’ve highlighted the last bit because I think it speaks to something vitally important to the nursing profession, but often lacking: a sense of solidarity with your colleagues. Let’s say this plainly: either you stand with your colleagues, or you stand with the bullies. Afraid of retaliation or intimidation? You already have courage. You’re a nurse, right?

[Also, Sean Dent on the same.]

Observations and Assessments

Notions too small for a blog post all in one place.

April Foolishness. I guess I got  — or more likely annoyed — a few of you with my little April Fool’s prank. In case you missed it, I faked a news report from Trout Creek, Montana (pop. 261) stating the local hospital was going to fire all it nurses and replace them with housekeepers. I even put up a picture of some hospital in India, complete with palm trees (in Montana!). Some of you waxed quite indignant before realizing it was the First of April. What’s interesting is how readily people believed it — which speaks volumes about nurses’ perceptions about how they are valued by their employers. Which is to say, not much.

Nurse goes all postal on Craigslist. This epic rant has been making the rounds — those with delicate sensibilities may want to avert their eyes:

Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money.

I know, “some people got jobs”. That does not justify the majority (1000’s) who did not and are now working retail for minimum wage. There is something fundamentally wrong with this country. My school counselors, nursing instructors, media and nurses I know urged me to go into nursing. As soon as I got my degree and the check to the school cleared I heard the unmistakable sound of the door to nursing closing—slamming actually. And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.

It is over. I am a stale grad and I am out of options. The new graduates fresh out of their precepts will be flooding the market to add to the already rancid oversaturated pool of disgruntled STALE GRADS. So, I guess giving up a nice job for school, dedicating 6 years (yes, I was foolish enough to get the BSN), dropping 20 grand and putting up with nursing school stress was all for nothing.

And no, higher education is out for 2 reasons. One, you need RN experience to qualify for any NP program. Second, why would I throw more money at a system that just failed me and ruined my life? It is clear that the educational system is bunk. I am completely embarrassed at the education I experienced at the California State University–It is appauling.

I hate nursing. I hate it so fucking much now. The true colors of the profession are now clear. So, now society can have a derelict because that is what I intend to become. I now plan to make a living mooching off the system.

It would probably take a year of posting to unpack all of this. Suffice to say, I do have the tiniest bit of sympathy for her, as I graduated at the nadir of nursing joblessness in the ’90s and was forced to work part-time for the first three years of my career. That being said, I wonder at her commitment to the profession, despite the six years of expensive education; one senses she wants her dream job handed to her on a platter. It doesn’t work like that. So I’m with everyone else: don’t let the door hit you on the way out. Or else come to Toronto — I know some 5 North nurses who would love to have you as a colleague — and they’re hiring.

Uterus, uterus, uterus. In another take to the uterus-as-filthy-word story, now you can incorporate your womb. (Thanks Terri!)

Take me to your leader. In case my American friends and readers haven’t noticed, we’re finishing up the second week of a federal election campaign, where the forces of light and the agents of doom and darkness will collide in a colossal battle for the heart and soul of the nation, etc. Being the flaming left-wing commie-pinko-socialist I am, I will prevaricate until the very last minute till inevitably holding my nose and voting Liberal. All which is to say, if I seem more, um, political in the next few weeks, I can’t help it, it’s the environment.

Hope they were praying for epinephrine. Speaking of Members of Parliament, there’s a report in the Le Devoir this morning that three Conservative MPs witnessing a severe allergic reaction on a flight to Taiwan responded by laying on the hands and praying. I guess I slept through that part in my critical care courses where Prayer comes before Airway, Breathing, Circulation. [ Via. ]

Non-nursing blog shout-out:  Worcester College Gardeners — actual professional gardeners charged with the maintenance of 26 acres of grounds surrounding Worcester College , Oxford, U.K. Reading through the blog puts lie to the notion of effortless gardening: it becomes quickly very apparent all those charming, perfect English garden scenes Canadians wax green over are the result of some pretty intensive labour. What I could do with a flock of minions and unlimited cash!

A pair of quacks. I was happy to learn that both Mehmet Oz and Andrew Wakefield, the fraud-mongering anti-vaccination advocate, were recipients of the annual Pigasus Awards. Oz — and any self-respecting  nurse is always glad to see him taken down a notch or two — was given the award for promoting such quackery as energy fields and faith healing and advocating the bereaved call a psychic for consolation. (Why is this jackass still on television?) Wakefield got the award for continuing to peddle his nonsense despite being called out by the Lancet and the British Medical Association.

Mini-rant. To anyone who has cut and paste from this blog: it has come to my attention bits of my writing — which I remind you are not free, in the sense you can use them at will — are being circulated unattributed and altered contrary to the copyright notice on the bottom of this page. Please note that even if you did not see the copyright notice, you are still subject to its provisions. In other words it is your responsibility to ascertain your obligations.

I really don’t mind people lifting my writing so long as it’s unchanged and attributed to me. I actually like it, because it’s free publicity. But when I find my original work altered to the point where my authorship is in doubt, it starts to piss me off. When you don’t link back to me, you become a thief.

P.S. When I write “shit” I mean “shit”, not some milquetoast euphemism you have determined won’t offend your readers — which  incidentally doesn’t nullify the copyright either.

P.P.S. Why do I think it’s a losing battle?

Accessing CVADs is Like Killing Puppies, Only Worse

A little while ago I was seconded to do some administrative-type work, and one of the things I was asked to do was certify ED nurses in central venous catheter access. CVADs — central venous access devices —  include such things as Hickman catheters, implanted ports and PICCs (peripherally inserted central catheters). They are typically seen in chemotherapy patients or dialysis patients, or people who require very long-term antibiotic therepy, or frequent venous access.

CVADs are fussy and fastidious, rather than difficult; they are somewhat time-consuming and they demand good preparation and strict aseptic technique. In the emergency department, we use them principally to obtain blood draws and to start IV therapy. They are certainly becoming more common, even as the population ages and community care options become more feasible. The case for ED nurses acquiring this skill ought to be a no-brainer: decreased patient discomfort, no new invasive procedures for blood draws and IVs — not insignificant considerations for patients who might be immunocompromised. Unlike many hospitals we have no vascular access team; getting bloods or starting IV therapy was left to the two or three of us who were certified in CVAD access. My job was to get a critical mass of nurses certified so there would be at least a few competent available on every shift. A pretty straight-forward task, or so you would think.

I was frankly taken aback at the vehemence of the resistance to to this initiative. “It’s the worst decision this department has ever made!” one nurse told me in tones which suggested I had asked her to kill puppies with me in the soiled utility room. One interesting thing I noted was there seemed to be a distinct demographic divide. New(ish) nurses I approached for the inservice and certification seemed to be much more receptive* than the old birds (like myself) who were, um, more vocal in their objections. I get/don’t get the objection. I know nurses worry about increased workloads affecting their practice and patient care, I understand the difference between acuity and complexity — and CVADs do add a layer of complexity to patient care. But ultimately it’s about improving patient care — as using CVADs ultimately does. So what’s the problem?

I’m at a bit of a loss to explain this dichotomy. My hunch is that hospital administrators have manipulated and lied to nurses over the past  — what? two decades? — about how this or that new initiative or increase in workload will “improve” patient care, even when patently false, so often that older nurses have given up trying to figure out the the spin from the evidence. My other hunch is that newer nurses are more interested in evidence-based practice than us old dinosaurs — maybe. What I’m also not clear about is how this resistance can be changed into something positive. My sense is that it’s probably not worth the effort, and leadership is not enough. Am I wrong?

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*Or fearful of me.

How To Be Arbitrarily Kicked Out of Nursing School

In some states, public display of a placenta by a nurse is punishable by death

Want to get kicked out of nursing school? Display a placenta on Facebook.

The shorter version of this story tells of a director of nursing named Jeanne Walsh arbitrarily booting a student named Doyle Byrnes (right) from the from the nursing program at Johnson County Community College in Overland Park, Kansas only a few months short of graduation. Her heinous offence? She published on Facebook (with her instructor’s permission, mind you) a photograph of herself beside an anonymous placenta. In the letter of expulsion Walsh was brutal, yet undoubtedly fair — at least in her own mind. She wrote Byrnes: “Your demeanor and lack of professional behavior surrounding this event was considered a disruption to the learning environment and did not exemplify the professional behavior that we expect in the nursing program.”

I am mystified and not only by the Walsh’s evasive, accountability-shifting use of the passive voice. All I see here is an obviously excited, eager student with the “shiny shultz” side of the placenta showing in a tray.* Bad taste? Debatable. It’s certainly no worse than reality television. It’s not as though she’s swinging the thing around by the umbilical cord. Maybe instead of the contagious grin, she should be frowning at it slightly. Is there some gross violation of nurse-placenta confidentiality I’m missing?  What, did the placenta call to complain about its treatment?

Not Nurse Ratched had the best comment:

JCCC says it’s “a lesson hard learned.” Indeed, but not the one the school probably thinks it’s sending: the lesson is that nursing is filled with inexplicable decisions and finding out after the fact you did something Bad. This student can carry that lesson with her, but is it really one our nursing schools should be teaching? Can they not teach something more like “here’s an opportunity for education regarding healthcare and social media”?

Yep, indeedy, that pretty well sums up this school’s competency. No warning letter, no chance at remediation, just straight out the door. Nothing like grabbing the figurative axe for fixing a problem —  and incidentally demonstrating the nasty underbelly of nursing. Makes you wonder how this school reacts when a student actually does something serious.

So a few conclusions: first, Johnson County Community College’s nursing program is probably — well, let’s be kind and damn with faint praise: they do their very best, despite having no sense of proportionality — or humour. Second, higher degrees in nursing are evidently not guarantees of effective skills in either nursing education and administration. Third, we often talk about nurses eating their young. After seeing this story and hearing about others like it —  and it truly pains me to say this — I’m beginning to wonder if the source lies in nursing educators inculcating those old-fashioned nursing “values.” You know, the ones that say arbitrary and unjust behaviour, back-stabbing and treating nurses as expendable are acceptable. After all, isn’t this a classic example of how colleagues and superiors knee-cap young nurses and students?

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*Note to AtYourCervix: I was not sleeping all the time during my Obs/Gyne rotation.

Maxims for New Graduates

Courtesy of Will Hardy

Will Hardy over at Drawing on Experience wanted advice for new grads.  My two cents.

Learning never ends.

Learn by doing.

See one, do one, teach one.

Pay attention when a patient complains of imminent death.

Go to codes.

Never pass up the opportunity to see a procedure.

Not everything can be fixed.

Eat.

Pee.

Breathe.

Patients die unexpectedly for reasons unrelated to the quality of your care.

Don’t think you know more than you do. You don’t.

Ask for help.

Ask questions.

More importantly, know when you must ask questions.

If you still don’t understand, ask more questions.

Advocate. For your patients. For your profession. For yourself.

Be skeptical.

Critical thinking is not optional.

Bedbaths are an essential skill, even for RNs.

Chart. Then chart some more.

Read Notes on Nursing.

Walk before running. Basic nursing before Swan-Ganz catheters.

Listen. Carefully. When someone offers you a piece of chewing gum, you’re not thinking your breath stinks, right?

ABCDs.

Wash your hands.

Foley catheters are not a substitute for good nursing.

Housekeepers and ward clerks are your best friends. Treat them as such.

Bring chocolate.

Your most recent assessment is the most important one.

Find a mentor.

Sixth sense counts. Ignore it at your peril.

Five rights. Three checks. Always and forever. No exceptions. Ever. Amen.

If you’re giving more than two of anything — tablets, capsules, vials — you’re giving too much.

If your colleague is drowning, throw her a life ring.

Specialize in a skill. Be the go-to guy for hard IV starts.

Make it your rule: take no shit from anyone.

Feel free to add your own: I’ll make a page for them.

[Update: Will’s cartoon added]

Hildegarde Speaks

Courtesy of the ever-resourceful Vernon Dutton (Twitter ~ Flickr). The interview has been unfortunately truncated, but it still well worth watching.

Peplau on editors who wanted to mangle her book: “No, we’re not going to do that.”

Hildegarde Peplau’s Yearbook

Vernon Dutton (Twitter ~ Flickr) this morning sent me photos of Hildegarde Peplau’s yearbook, which he describes as a “lucky find”. I won’t pretend omniscience; I remembered her from school as a theorist who proposed a paradigm of nursing care, and that was about all. Callow youth: I didn’t pay enough attention.  She was, of course, much more.

Hildegarde Peplau graduated from the Pottstown — a small city in Pennsylvania — Hospital School of Nursing in 1931. With some condescension, we now tend to think the middle years of the last century as the dark ages of nursing: think outlandish (to our eyes) caps, starched dresses, white hose and white patent-leather shoes — with heels! The vast majority of nurses were “hospital trained” in one or two years, i.e. as trainees, they lived on hospital grounds under a regimen second only to convents for rigidity and discipline, and their education, with a strong emphasis on practical nursing, was entirely within hospital walls.

From modest beginnings, however, Peplau went on to obtain her bachelor’s degree, then a master’s and doctorate; she became a certified psychoanalyst and expert on psychiatric nursing. Her greatest achievement was the publication of her work, Interpersonal Relations in Nursing (1952), which established a firm theoretical basis for nursing practice,  profoundly influenced the practice of generations of nurses to the present day, and made possible the establishment of nursing as a profession.* She held numerous chairs in nursing at universities around the world, acted as consultant to several agencies of the U.S. government, and was awarded eleven honorary degrees. Towards the end of her life, she said with some prescience:

Nursing has made great progress from being an occupation to becoming a profession in the 20th. Century. As the 21st Century approaches, further progress will be reported and recorded in Cyberspace — the Internet being one conduit for that. Linking nurses and their information and knowledge across borders — around the world — will surely advance the profession of nursing much more rapidly in the next century.

In looking over the photos from this long-lost age, we can scarcely sense the potentiality of these new graduates and of Peplau in particular. Friendly and eager faces, yes and kind, but not ones, you might think, who would run out of Pottstown, Pa. and change the world. But that is exactly what she did. Under Peplau’s picture, though, is the comment which just hints: “All she needs is a soapbox to make her arguments forceful.” When I reviewed her theories, dragging out an old textbook or two, I was quite surprised how much her work — consciously or not — has influenced my own practice and the way I look at nursing, that is, seeing nursing as a collaborative, learning process between the nurse and patient, in order to restore health, and how in this process nurses take on a multi-faceted roles.

We — nurses and patients — all owe her more than we know.

[Photos used with permission.]

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*Incredibly, publication of her book was delayed four years because it was though inappropriate for a nurse to publish without having a physician as co-author.