Posts Tagged Registered nurse

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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How Nurses View Themselves

A selection of “What I Actually Do” meme posters” related to nursing, which have been making the rounds on the Interwebs. Some of them, I guess, are funny and clever, and they’re meant (I suppose) to educate the public at large about the realities of nursing. But what I think is interesting is the way they reflect nurses’ perceptions of themselves, and how nurses perceive how others view them. Some common themes: nurse as lazy (by managers), nurse as bimbo, nurse as angel, nurse as waitress/bellhop, nurse as money-grubbing, nurse as menial. What do you guys think of them? Do they actually represent how nurses view themselves?

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Observations and Assessments

NOTIONS TO SMALL FOR A BLOG POST, ALL IN ONE PLACE, A.K.A. THE PERIODIC LINK DUMP.

Further to my post “Sleepy Sleepy Nurse”: Sleep or Die. Really.

My jobRegistered Nurse.

We don’t know as much about infection control as we think we do. “Less than a quarter of the Clostridium difficile cases in a hospital could be traced to patients in the same ward, challenging a common assumption about how the infection spreads.” Medscape summary. Original article here.

And we’re not as smart at Triage as we think we are. Analyzing the records of 519 patients aged 65 years or older who were triaged using the Emergency Severity Index, from University Hospital Basel in Switzerland, found that 117 patients were undertriaged and 15 were overtriaged.” Anecdotally, I think this is true. My only quibble is why the small sample size? I mean, 519 patients is two days of volume in a busy ED, which means only a few poorly trained triage nurses could skew the results.

Nurses’ Presenteeism and Its Effects on Self-Reported Quality of Care and Costs. I read the article and went “Meh.” Rather evades the real issues around presenteeism, i.e. workplaces penalizing nurses for taking sick time.

Oh, dear.

On the menu: Pink Slime! I swear I will never, ever buy ground beef ever again.

And they didn’t live happily ever afterReal life Disney princesses, fallen. A photo exhibit by Dina Goldstein. My favourite: Cinderella knocking back shots in a bar on Hastings Street in Vancouver’s Downtown Eastside.

Younger than the Happy Meal. An important reminder from Fred Clark the supposedly “eternal” truths about abortion maintained by evangelical Christians are of much more recent vintage than you think.

Great music in the cause of crap content. Dissecting the cultural significance of country music. Quote:

The conservative movement has been cannibalizing conservative art for years now, to the point where I’d say country music is far from a victory of conservative cultural or artistic success and is instead a mirror image of what conservative politics have become: easy and unthinking. No depth, all surface. Superficial and insular. Maybe I’m wrong, but building an entire genre on the back of the idea that regurgitating the same sound on top of the same basic premise over and over again hardly strikes me as a triumph of cultural conservatism.

What language do deaf people think in?

Ayn Rand is the Karl Marx of the Right. Mostly because she tells people with incredible amounts of privilege they are the real victims in life’s lottery. Quote: “She offers them something that is crucial to every successful political movement: a sense of victimhood. She tells them that they are parasitised by the ungrateful poor and oppressed by intrusive, controlling governments.”

The Reformed Whores respond to Rush Limbaugh: “I’m a slut.” Hugely funny and right on the money.

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Just Lie Back and Think of Florence — Or Not

Nurse K, possibly the doyenne of nurse bloggers, gives her two cents on Amanda Trujillo. Her advice is to surrender:

Yes, I’m going to say it: Forget advocating.  Be humble.  Be honest and consistent.  Go through the process.  Listen to your attorney.  Your most important asset as a terminated person is an unrestricted nursing license and lack of bitterness.  Get advice from your attorney and mentors about what to say in job interviews about your termination.  Rehearse your answers to the question of “why were you terminated from Banner Health.”  Don’t decide that you’re never working for a hospital again and you don’t care what anyone thinks. You’re a single mom on welfare with a termination on your record; you don’t have the luxury of being picky. 

This termination was not about who can order a case management consult.  This was the typical crap that I saw every day.  Someone important (in this case, the surgeon who was to perform the transplant) [it was a gastroenterologist, not the transplant surgeon,  incidentally — ed.] looks bad or is pissed at someone for something and demands a termination and the thing spirals out of control.

This type of stuff is a hospital culture problem and certainly needs to stop, but a terminated employee is not going to stop anything like that, so don’t expose yourself to the world as a fired person with a chip on their shoulder. 

Well, fair enough. You pick your battles. What she’s suggesting is that for Amanda Trujillo, maybe this wasn’t the hill to die on. This is true in some, maybe even most, cases. It is excellent advice, in fact. I have a friend whose employer reported her to the College of Nurses of Ontario  — the semi-equivalent of state boards of nursing — for a serious med error that contributed to the death of a patient. She went through the process, humble and contrite, and received a formal written caution and oral reprimand.  Her employer supported her through her rehabilitation, worked out a mentorship and learning plan with her; she took a refresher course on medication. She is still practicing. This is how the system is supposed to work, right?

To paraphrase Queen Victoria, just lie back and think of Florence. I don’t think I am caricaturing Nurse K’s position here, not much anyway. Most times, silence is golden and discretion is the better part of valour, and all those other platitudes your mother taught you.

But then, this isn’t a conventional case. Let’s review for minute: Trujillo offers a patient information regarding an organ transplant and arranges, as per usual practice and at the patient’s request, a hospice care consult; this angers a physician; she is arbitrarily fired for exceeding her scope of practice in ordering this consult, which was inside her scope the day before; no one was harmed or put at risk, except, perhaps, the physician’s ego; Banner Health, Trujillo’s employer, reports her to the Arizona State Board of Nursing for practicing outside scope of practice  which — I can’t say this enough — was practicing inside scope of practice the day before; the case languishes for months and months in some sort of bizarre Board of Nursing limbo; then the moment Trujillo’s case caught the attention of some ratty-end nurse bloggers, the Board of Nursing orders a psych consult, evidently because publicly defending yourself makes you crazy; the Board of Nursing subsequently (and in a highly dubious fashion) informs Trujillo’s university she’s under investigation, then denies it despite clear proof to the contrary; and now the latest buffoonery, a new accusation from the Board of Nursing that Trujillo has “misrepresented” herself as to her academic credentials.

If this is a typical case, we are all in trouble.

And there’s this observation: isn’t shutting up and going away what employers and managers and nursing boards expect front line nurses to do? Don’t make trouble, nurses. It’s unbecoming. It will just make things worse — yes, for you. Don’t advocate for yourself — because — we will call you crazy. You will be screwed over — and you will like it!

The thing is, even before all the fuss, it’s hard to imagine how this could have gotten worse for Amanda Trujillo. If the fix is in, if you’re being railroaded by your employer, and the state Board of Nursing (as Nurse K says) is shady and duplicitous, being demure and helpful and willing to take your lumps is not going to help you. And why in the name of everything that is sacred and good should you help someone who is seeking to harm you? And as for meekness and docility now? Seems rather besides the point now.

In any case, nurse as silent martyr is not a great image. Nurse as battered wife is worse. Advocacy for yourself, and for your profession is sometimes not one of many bad choices, it is the only choice. Because of circumstances yes, but also because it is right. And as Nurse Ratched points out, often it only takes one pebble to start an avalanche.

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The Persecution of Amanda Trujillo

In the ugly, grey world of hospital balance sheets it’s almost a commonplace that physicians generate revenue while nurses represent a cost. Fancy procedures and sub-sub-specialties bring generous income streams, in terms of charging (and profiting) from the provision of a multitude of related services, such as nursing, while nursing itself, because it generates no revenue, is a burden to the bottom line.

It’s also commonplace, that in certain health care institutions, the power structure, the hierarchy of heath care, is so rigid (and fragile) that any challenges to that hierarchy — such as a nurse questioning the God-like omniscience of a surgeon — must be ruthlessly suppressed.

Amanda Trujillo

So when a nurse interferes with the revenue stream, dares to challenge the organizational power structure, hospital’s only logical recourse is to utterly destroy the nurse’s career. Take the case of Amanda Trujillo. Engaging in standard, no, gold standard nursing practice, following hospital procedures and using hospital materials, Trujillo correctly ascertained a patient facing end-stage liver disease did not understand a proposed transplant procedure or its consequences, and desired palliation instead. According to usual practice at this institution, and with the support and knowledge of her immediate manager, she requested a multi-disciplinary team consultation to create a care plan.

Amanda Trujillo tells the story herself:

My name is Amanda Trujillo. I’m a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care. Back in April of this year I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care). The patient also had no idea that they had a choice about whether they had to get the surgery or not or that there were other options. They asked about hospice and comfort care and I educated the patient within my nursing license and the nursing code of ethics. The patient requested a case management consult to visit with hospice to explore this option further in order to make a better decision for their course of care. I documented extensively for the doctor to read the next day and I also passed the info on to the next nurse taking over, emphasizing the importance of speaking with the doctor about the gross misunderstanding they had about the surgery. The doctor became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken. He was successful on all counts.

Let’s be clear about this and speak plainly: when the transplant surgeon primary physician found out about this course of events, mindful perhaps of lost fees, but heedless (it seems) of any apparent conflict of interest, and in fact, of any basic recognition of the principle of patient autonomy, he threw a temper tantrum, and demanded the job and licence of Nurse Trujillo.

The administrators at  Banner Del E. Webb Medical Center, heedless both of any apparent conflict of interest on the part of the surgeon primary physician, and in fact, of any basic recognition of the principle of patient autonomy, complied with this request. In the best tradition of blame-the-nurse, these faceless administrators — and I sincerely hope there are no nurses among them, because if there are, they are a complete disgrace to our profession — fired Amanda Trujillo. They then reported her to the Arizona State Board of Nursing, on the grounds that the request for the case management team somehow constituted a “medical” order, and therefore Trujillo exceeded her scope of practice. It’s important to realize these (hopefully-not-nurses) administrators designated this particular order as a “medical” order somewhat after the fact.

Very disturbing is the sheer maliciousness of the hospital administration at  Banner Del E. Webb Medical Center. Think about it for a minute. Even if you accept — and this is a  long stretch — that Trujillo exceeded her scope of practice, is the appropriate, measured response to ruin her practice, when the “error” was made in the best interest of the patient, in way that recognized and validated the patient’s right to autonomy?

Yet at some point an administrator decided the only appropriate, measured response was to utterly destroy the career of this nurse by screwing her over so royally she could never practice again.

(Nice job, Banner Del E. Webb Medical Center! I guess the best thing about this hospital you can say is that it it’s an awesomely bad, ugly, abusive place to work, if they would throw a nurse under the bus to appease a physician having a temper tantrum. It almost goes without saying that a place that is bad and ugly for nurses to work in doesn’t do much better for patient care. The case, in the event, pretty well makes that much clear.)

Amanda Trujillo’s hearing at the Arizona State Board of Nursing was supposed to have been yesterday. It was postponed for two months for a psychiatric evaluation because — wait for it — defending one’s self publicly on the Intertubes constitutes “retaliatory behaviour.” No, seriously. In the old Soviet Union, dissidents used to be labelled insane to discredit and marginalize them. Pretty well much the same obtains in modern nursing. Defy a physician, you get fired, you get investigated, and you get labelled crazy. And the Arizona State Board of Nursing facilitates the abuse, because as we all know, health care institutions never lie, and never have ulterior motives.

Nice.

So you want to be a nurse?

__________

Amanda Trujillo’s full story can be found here at Vern Dutton’s site.

Her Twitter feed is here.  Trujillo’s Twitter account seems to be deactivated this morning (26/01/12).  

Amanda’s new Twitter feed is here.

A Facebook page in her support is here.

Email the Executive Director of the Arizona State Board of Nursing, Joey Ridenour, RN, MN, FAAN: jridenour@azbn.gov

Complain to Banner Health here.

Nerdy Nurse’s perspective is here and here.

Please spread Amanda’s story as widely as possible. Every nurse is vulnerable to mistreatment.

UPDATE: 

Minor spelling corrections. Anyone know where I can purchase a hobbit to proofread?

Also:

Emergiblog:

Nurses not only eat their young, but God help you if the almighty Medical Establishment gets ticked off.
Nurses talk a great game. In the Halls of Academia and the Ivory Towers of Those Who Claim to Advance The Profession, it’s all “Nursing Is An Independent Profession” and we tirelessly “Fight For Our Right To Practice To The Full Extent Of Our Education And Training”.
Unless you’re down in the trenches doing patient care every day and someone gets angry that you have dared to advocate. And if that Someone is a Doctor, well, the bigwigs scatter to the four corners of the ring.
Musn’t create controversy.
Hell, they aren’t even standing on your side of the arena.

From Kim we also learn that the president of the Arizona Nurses Association (email the Executive Director, Robin Schaeffer: robin@aznurse.org) is the nursing director of Banner Del E. Webb Medical Center. Hence the deafening — and telling — silence of that organization.

And also Jennifer Olin. And NurseKeith.

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A Matter of Hours

I was talking the other day to young, surprisingly old-school physician who bemoaned nurses “doing things” she thought properly done by duly authorized medical practitioners. (She also implied, by-the-by, that when physicians said “Go fetch,” the proper nursely response was a demure “Yes, doctor, and do you want your neck rubbed?)” Clearly, this physician thought, medicine was the senior and superior discipline, and nurses should defer at all times to their judgement, even on matters clearly within the sphere of nursing. Her basis for this line of thought was that physicians got “thousands and thousands of hours” of clinical and classroom education while nurses only had a “few hundred hours of  dubious training.”

My head almost nodded, subconsciously anyway, in agreement. Got us there. It’s a common theme, actually, when you see discussions of nursing versus medicine. Nurses just don’t have the education, it’s claimed, to make the really important decisions in patient care. But then I thought about it for a bit.

Leaving apart the obvious — that medicine and nursing are two different (if related) disciplines — in point of fact, I had 1950 clinical hours and about 2000 hours of classroom study to become a Registered Nurse — and this doesn’t include the hundreds of hours more of post-graduate education to gain speciality certification and also training for things like ACLS and TNCC. I know it doesn’t compare to the extensive/intensive training of physicians. But still, nearly four thousand hours of formal training as a minimal entry to practice is nothing to sneeze at either, and hardly the “few hundred hours of dubious training” imagined by some physicians. At any rate, it makes me wonder why, given our own expertise, education and experience, why some nurses continue to be cowed by claims of physician superiority?

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All I Can Manage Today are Random Thoughts

Just can’t get into the groove today: started two blog posts and after writing a couple of paragraphs, they both look like gibberish to me. Funny thing is, this is the very first completely free day I’ve had in a couple of weeks, and I had planned to get some serious writing done today. Focus seems to be the problem. Maybe it’s the fact the house looks like a hobo camp, or that the pile of laundry is rapidly gaining altitude, or that I have a some minor, yet pressing chores to do — in any event, the Muse has gone elsewhere today.

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One of the speakers at the Trauma Nursing Conference I went to a little while ago was from the Society of  Trauma Nurses, which seems to be principally known for providing the Advanced Trauma Care for Nurses course. STN markets itself towards the “leadership of trauma nursing around the world” and yet its stated aim is “become the premiere nursing organization in the world for advancing the nursing care of injured patients.” It might be the February crankies talking, but does anyone else see the contradiction in this? Or the condescension? I mean, how can anyone talk about being the best nursing organization in the known universe, while ignoring the front line? Isn’t leadership and excellence for all nurses? Incidentally, the speaker, Deborah Harkins, mentioned that on a membership survey 477 nurses identified themselves as “leaders” while only 36 were front-line staff. She didn’t seem to think this was a problem.

After Harkins gave her talk, I asked my table mates if any of them intended to join STN. Much hilarity ensued. My guess is that until STN changes its membership philosophy, its goal to be the gold standard for trauma nurses will prove elusive

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More about the conference. It was actually pretty well done, and worthwhile attending.  Only a couple of presentations were out-and-out duds. But I have to ask: perusing the program, why were the vast majority of presenters physicians? At a nursing conference?

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I saw a disturbing bright light in the sky the other day. Oh right, it was the sun.

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I’m going to clean out my linky-loos on the blogroll later today, maybe, after I do the laundry. Anyone have any tips on good nursing/health care blogs to add?

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Still no word about the leap to the Dark Side. I’m not that anxious about whether I got the job or not. But I dislike the wait. It’s like being told, “We are going to make a life-altering decision about you or not, and we’re going to string you along until the last possible moment before we reveal our choice.” That’s what aggravating.

 

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Credentials are Good. Credentialism is a Serious Illness.

In 2005 a baccalaureate degree became the standard for entry to registered nursing practice in Ontario, and there was a scramble in the years preceding to set up collaborative programs between the CAATs (colleges of applied arts and technology) which had previously administered the three-year diploma programs and the universities who would be granting the new four-year degrees. During this process, one new university program I am familiar with rather haughtily decreed that no mere BScN (or, God forbid, a diploma RN) would sully the ranks of its clinical instructors, most of whom taught part-time in the CAAT system while working full-time clinical positions. You see, BScNs couldn’t possibly teach clinical: they didn’t have the proper credentials, despite having years of experience that collectively ran into centuries. The university nursing program then proudly hired MScNs and Ph.Ds to fill the very large holes left by the departure of the BScNs.

An excellent plan — until the program administrators realized all their new hires had little or no actual front line, bedside clinical experience. I suppose they had read about it somewhere. However, it quickly became evident they were not competent — and were even dangerous — acting as clinical instructors.

Unqualified.

I was thinking of this story when I read Terri Schmitt’s excellent post on her blog about the push for not just graduate degree holders in nursing programs, but nurses with the degree in the somewhat esoteric field of nursing education:

I think nurses with graduate degrees in nursing education are critical to the education process.  However, I recently was made aware of one nursing program that openly told its faculty that they will not get promoted if they do not have a degree in nursing education. This proclamation was made after they had hired nurses with degrees in clinical areas like CNSs or NPs.  Those faculty members, some who are the most clinically competent that I have ever met, were basically told that they were second class citizens.  To me, and this is purely my observation, it had the feel of lateral violence.

I am not clear, exactly, what exactly a degree in nursing education means, and why nursing (alone of any profession, or indeed any academic discipline) needs a speciality to teach itself. Is there some previously unknown aspect in the pedagogy of nurses which uniquely requires this degree? I’m doubting it. A quick online search reveals MScNs in “Nursing Education” from such places as Jacksonville University and Drexel University in online courses. The cynical portion of my brain — admittedly a large part — thinks that “nursing education” programs are less an academic discipline than a niche marketing position, to differentiate themselves from a “generic” MScN. “Nursing Education” may well be a credential too far, but yet it seems some nurses have bought into it.

Unqualifed.

Nurses are very quick to add letters of all shapes and sizes after their names. We see not only degrees, but certifications and specialities, and even degrees not yet awarded. (My personal favourite is the MScN (Cand.), which I have observed lingering after some nurses’ names like a bad smell for years.) I have often puzzled over this obsession with credentials in nursing. It worries me, a little, that in the push and requirement for ever more exotic credentials, nursing will lose a great deal of diversity and perspective, especially in its leadership. Think that Florence Nightingale, who despite prodigious accomplishments, would not be qualified to teach at the university program I mentioned above. Hildegarde Peplau, who revolutionized nursing education and the nursing profession, would be fired because she didn’t hold a degree in “Nursing Education.”

Unqualified.

Credentials are good, as far as they go. They are a public declaration of qualifications. Credentialism, where degrees are unthinkingly required for their own sake in the vain hope of producing some undesirable uniformity, is the result of some very unflattering pathology in the nursing profession. Nurses and nursing still tend to undervalue their degrees and education, especially vis-à-vis physicians. Wielding degrees has become an exercise in compensation. Having the “speciality” of nursing education is just another way to do it. In this context, Terri Schmitt is probably on the money when she suggests some nurses use their superior education as a weapon.  Personally, I do get a little tetchy at the inherent, unspoken assumption the granting of any graduate degrees confers some magical superiority as a nurse. I don’t see see the point of knocking down one part of the profession to build up another. We all need to go forward together. All nurses have a valuable contribution to make to our profession, not just the ones with long strings of letters following their names.

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More on Independent Judgement

Independent judgement may count for squat if the doc doesn’t listen to you. One of my spies in the Ontario health care system tells me the story of  a 60ish year-old woman, a known drinker, who came into an Emergency Department with an altered level of consciousness. Ethanol level comes back elevated, so end of story, right?

Unfortunately no. The primary nurse advocates for this patient. She’s seen cerebral bleeds, and she’s seen drunks, and she’s seen bleeds and drunks in the same person, and moreover, she has watched this patient subtly deteriorate for the last three hours. She tells the Emergency Physician, “Hey, this patient isn’t right. Her neuros are whacked. She needs a CT of the head.”

The EP is the sort of doc who, if a nurse said “Feces”, would say “Fudge, and please pass the plate.” He refuses to order the CT, and instructs the primary RN to discharge the patient.

The nurse absolutely refuses. The patient needs a CT, the nurse says.

The EP gets all huffy. Fine, he says. I’ll pull the IV and discharge the patient myself. Take that, you dumb know-nothing nurse!

Of course, you know the sequel. Patient returns a short time later, twenty times worse, coags are screwed, finally gets the CT, which (naturally) shows a cerebral bleed; she’s shipped to a Big Toronto Hospital, and blah, blah, blah — hemorrhagic stroke.

Independent judgement — where a nurse can effectively advocate for their patients — will only work in environments where there is a culture that treats the professional opinion and judgement of nurses (and other health care professionals) as valuable and meaningful in effecting good patient outcomes. Unfortunately, in many health care settings (the majority?), such as perhaps this Emergency Department, this isn’t the case. The quality of patient care accordingly directly suffers as a result.

I’m also reminded of an article I saw the other day about moral distress — the anxiety and suffering caused by being unable to act upon one’s own ethical values — and the risks it poses to nurses personally and professionally: dissociation, apathy, leaving nursing altogether. I suppose moral distress would include being discounted and minimized, advocacy being at the heart of ethical nursing practice. I wonder if there have been any studies linking patient outcomes specifically with moral distress in nurses, and if not, whether this would be a fruitful topic for investigation.

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Slightly Used Posts: Poo Free

A repost of one of my (IMHO) better entries in the past year, to mark the first year of this weblog. First posted November 2009.

No more poo:

Student nurses are rejecting essential elements of bedside care because they feel it is not a worthwhile learning experience, research published by Nursing Times has found.

The research found widespread conflict between student nurses and qualified staff over the tasks students should do on placement.

Tasks normally carried out by HCAs, such as making tea, washing patients and cleaning, were not seen as valuable learning opportunities for student nurses keen to gain experience with more technical roles like administering drugs.

As a result, many senior nurses feel that students are qualifying with significant gaps in their basic skills. One interview participant said: “I sometimes feel in despair that by the time students have qualified, they still haven’t gained some of the practicalities and common sense – things like time management, basic assessment skills – that we would have been doing on our first round.”

One student was reported to have told a staff nurse: “I keep being asked to do things which won’t help me learn – clear up poo, mop up blood, give patients tea and toast. I realised that I needed to more focused to learn, and I don’t do those sorts of things now. [The full study is here.]

I’m actually with the students on this. There are few things going on here. One is the perpetual nostalgia that nurses have for the good old days, when men were men and nurses were nurses, and we were trained by battle-axe old-school-types who flogged us students daily with used foley catheters before we walked home uphill in a blinding snowstorm to work all night on 45-page-long care plans. And that somehow produced wonderful, thoroughly trained nurses, unlike today’s crop of know-nothings. So say a lot of you, including many of my own colleagues.

Oh honey. I have a newsflash for you. We weren’t that good, or well trained, and we fumbled around just like today’s new grads. I know. I was one of you.

And then there is a notion that since we went through all that crap that Hilda Harridan RN made us do, the current generation needs to “pay its dues” too. Though it escapes me how making nursing student go through their paces like we did will make them better nurses.

From the times I walked the floor as a clinical educator, I spent a great of time defending my students from the sort of crazy, useless busywork that the ward staff seemed determined to make them do. Staff believed they were free, exploitable labour. The manager of one of units told me, “They will be great help for the nurses.” She grew shocked and angry when I suggested they weren’t peons or gophers, and accused me of not teaching the students proper “teamwork”. This in her eyes seemed to mean making the students do the pissy things no one else wanted to do. My students, in fact, were not there to fluff pillows, cart patients to x-ray, boil the kettle, organize the bedsides, take specimens to the lab or any of the innumerable trivial tasks that can consume your average med-surg floor.

They were there to learn.

And I still don’t see how making a cuppa for the dear in 6 or running that routine R&M downstairs will help nursing students in time management or pharmacology — which seems to be the prevailing attitude in clinical areas. Good nursing skills come from hours of doing patient assessments, developing advocacy skills and learning to think critically.

And frankly, I would much rather have a nurse at the bedside with amazing critical thinking and communication skills than one who can effectively wipe the poo from my bum.

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