What Nursing Leadership Doesn’t Look Like

A small, belated Christmas tale on how not to manage an emergency department. But first a few preliminary points of information.

First: in Ontario, front line nurses are generally forbidden from taking vacation over the Christmas holidays, usually from some point from the first or second week of December to the first or second week of January. There are a couple of reasons for this: first, there are always staffing issues over Christmas. Secondly, if vacation time is granted by seniority, and if it werepermitted during the Christmas break, the most senior nurses would always get Christmas and New Year’s off, making merry while leaving their more junior colleagues to toil through the happiest time of the year. Hardly fair, and scarcely a morale booster.

My emergency department, Boxing Day

Most hospitals in Ontario will arrange scheduling in this way: nurses work either Christmas or New Year’s (either we pick or alternate each year) but we get five or six days off in a row over the holidays. Like any compromise, it inconveniences some people, but most seem happy about this arrangement.

Second: most Emergency departments over the holidays look like a merger of Bedlam and a random circle of hell from Dante’s Inferno. High acuity and high volume. I might add this holiday season war zone ambience is as predictable as, well, Christmas falling on the 25th of December. We just gird our loins and sally forth. Nevertheless, even halfway through January, we’re all a little crusty and stressed out.

So what would you say to a manager who takes vacation — and not a short one either — over the Christmas holidays? One of my minions has informed me that an ED manager at one Toronto-area hospital took vacation from roughly the middle of December to the middle of January. Needless to say, given all of the above, her staff are not impressed. They are angry. They felt abandoned at a time when leadership was needed. They resent the double standard, the flaunting of the no-vacation-over-Christmas rule. Some of them, I’m told, are so disgusted by this behaviour that they are actively seeking positions elsewhere.

I understand that managers deserve and are entitled to their vacations, and that from a staff nurse’s point of view of there may be no good time for a manager to take time off. Even so, taking vacation when staff cannot, and over time period when volumes and acuity are notoriously high indicates a certain amount of  — what? — cluelessness?

Management does have its privileges, but also has responsibilities. To me responsibility means sticking it out and providing leadership to your staff, even when it’s personally inconvenient. It might mean delaying a vacation for a month. It means not bailing out when you know things are going to be awful. This is good nursing leadership. Or am I completely off base about this?

UPDATE (22/01/12): Minor edit of mispelling. I need an editor, but can’t afford one.

Awesome

A few days ago, we had VSA come into the department. According to EMS, the patient had collapsed while grocery shopping down the road; CPR was started almost immediately by another shopper; EMS arrived and gave the usual ACLS drugs — epinephrine and atropine, as well as defribrillating him, but the only rhythm showing  on arrival was ventricular fibrillation. We shocked the patient again as soon as soon as we offloaded him onto a Resus Room bed — and (somewhat to the team’s surprise) the patient reverted a sinus rhythm with a palpable, if faint, femoral pulse.

Then the real work started to preserve circulation: intubation to manage the airway, peripheral IVs, drips of various inotropes and antiarrhythmics and sedatives to be set up, a central line and central venous monitoring, an arterial line,  foley catheter, and (at the same time) beginning the therapeutic hypothermia protocol, to preserve the brain from ischemic injury. Therapeutic hypothermia is itself  immensely complicated to implement, involving ice packs, iced saline boluses and iced continuous bladder irrigation to lower core body temperature below 34C.

As we were rolling the patient up to the ICU, I stood outside of myself for  moment and thought, “This was all pretty awesome. We have given this poor guy a chance to live. I have a really awesome job.”

And when we transferred the patient into his bed, he began opening his eyes. We weren’t sedating him enough. But that was pretty awesome too.

Under Construction

Meaning me, of course.

I worked a (rare) Night 12 a few days ago. It was the usual dog’s breakfast of high acuity, walking wounded without end lining up at Triage, and the particular Emergency Department hell of having no beds for, you know, emergency patients, the department being a stunt double for a med-surg unit. But there was a small ray of hope. Or rather it was okay news-sucky news situation. We were to get  a bed, the element of suckiness resting on the fact the bed was on 5 North, my perennial nemesis, where, I swear, reside the most obstreperous nurses in the history of the Universe.

(Excuses I have heard over the years from 5 North for not taking patients: too busy, patient too sick, patient too combative, patient [with normal vitals] too unstable, patient a drug abuser, patient HIV positive, on break, short-staffed, still on break, patient restrained, patient not restrained, swabs not resulted, patient unsuitable, no one to take report, too close to shift change, just about to go on break, you just sent us a patient, the bed isn’t clean, the patient hasn’t left the bed, the room needs to be cleaned, too late in the night, too early in the morning, the patient will disturb the patient in the next bed, it’s a male bed and your patient is female, still on break — well, I could on.)

So I told the primary RN to call up report. We need to move some patients in.

They won’t take report, came the reply. All the nurses are on break.

“What the hell?!? All the nurses?!?” I was incredulous. “How can all the nurses be on break?”

I called up to 5 North. “Can I speak to the charge?”

“She’s on break.”

“Can I speak to any nurse?”

“They’re all on break.”

“All of them?”

“Yes.”

“Who’s looking after the patients?” As one might imagine, I was becoming a little agitated.

“I am,” came the reply.

“Who are you?”

“I am,” said the voice on the other end, “the nursing student.”

Dear sweet Lord, I thought. “Let me summarize,” I said.  “You’re looking after 24 patients all by yourself, because all the RNs are on break?”

“Well,” said the student in a tone which made it clear she thought she was dealing with a plain idiot, “there’s a nurse sitting beside me.”

‘”Oh,” I said, thinking I had misunderstood the entire situation. “Can I speak to her?”

“No! She’s on break. I told you”

After which I lost it, just a bit. “So when your patient in 55 falls out of bed and fractures her hip because she’s been ringing the call bell for fifteen minutes because you’re trying to clean up the patient in 37, what are you going to do?”

“Oh, I’ll call the nurse to help.”

“But she’s on break!” I was nearly shouting.

Click. The student hung up on me.

Well, I thought. That didn’t go well. But then, after I went home and thought about it, wasn’t I guilty of the same bullying behaviour towards this student I have written about so critically? I heard afterwards I had reduced her to tears. Didn’t this make me the poster child for nurses eating their young? The student, after all, was not responsible for being placed in an compromising position, and being made to run interference against a nasty ED nurse (i.e. me) was fairly despicable. I should have recognized the circumstances and adjusted my own response accordingly — regardless of who answered the phone. In the heat and stress of the moments it’s all too easy to engage in awful behaviour and justify our bullying afterward in terms of providing good care or best practice. It’s all a lie. There isn’t ever justification for bullying. All I can say in my defence: I’m a work in progress. Like everyone

[Update: Yes, I misspelled “construction” in the title. I need a sub-blogger minion to proofread.]

On Allegations of Patient Abuse at St. Joseph’s

This story concerning alleged abuse of a senior at St. Joseph’s Health Care Centre (and yes, I know “alleged” is a weasel word) has been making the rounds in the Toronto media, including some blaring front pages in the Toronto Sun:

Ron Meredith claims two burly security guards at a west-end hospital manhandled him, dragged him to an empty room and shackled him to a bed like an animal.

The frail 79-year-old alleges he lay there unattended at St. Joseph’s — forced to wear a diaper — for seven hours until he was discovered by cleaning staff.

His only crime, he claims, is that he was sitting in a chair waiting patiently to be discharged.

“What they did to me was unbelievable,” Meredith said Monday, still in shock and covered in bruises two days after his ordeal.

Woken up by a noisy patient in the next bed, Meredith got dressed, went for coffee, and believing his discharge was imiment, sat down by the nurses station to wait. Unfortunately, the situation escalated.

He claims two security guards, “big guys,” approached shortly before 7 a.m.

“They accused me of trying to escape and told me to go back to my room,” Meredith recalled.

The senior explained he was waiting to be discharged but the guards again ordered him back to his room.

“I told them I was already dressed and I didn’t feel it was necessary to go back.”

After a third warning, he says the situation turned ugly.

“All of a sudden they pounced on me,” Meredith claims.

Both guards allegedly pulled him out of the chair, pinned his arms behind his back in a painful position and dragged him down the hall to an empty room.

“They threw me on the bed and I hurt my back on one of the rails,” Meredith said, adding the guards then cuffed his wrists and ankles to the bed.

“They really did a job on me,” he said. “And when that diaper was put on me I knew I was in for a long haul.”

Ugh. Nasty story. The thing is, as an old RN, I can immediately see suggestions there is much more to this story than meets the eye. The bruises, for example, on this poor patient’s arms are clearly old and related to IV starts or blood draws; they are particularly common in patients taking anticoagulants, which I strongly suspect this patient is on. They weren’t caused, in any case, by undue restraint. Further, one wonders if this patient refused a reasonable request to return to his room and wait for discharge; the patient then became increasingly angry and frustrated, and matters escalated from there.

On the other hand, as an old RN, I can clearly (and distressingly) understand how this story is completely plausible. Poor (or no) communication from the nurses on the inpatient unit to the patient and family on the care plan. Overreaction and assumptions made on the part of the nursing  staff. Stereotyping of the elderly as always confused and/or demented. Overuse of restraints. Underlying view of nurses that patients must be under control at all times. (Hospitals aren’t prisons!) Et cetera.

The point  is that there isn’t enough information to make an informed judgement one way or another, accusations made by the media notwithstanding. The problem is when health care horror stories — a favourite Canadian meme — appear in the press, it’s always a one-sided conversation. When hospital spokespeople say they cannot discuss the issue because of patient confidentiality, they aren’t being obfuscatory. Hospital administrators aren’t perpetuating a cover-up  By law, hospitals absolutely cannot make public patient information. This is to protect patients themselves. I mean, do you want information about you bum boil perianal abscess publicized?

The interesting thing for me is that the story, and how it is being played out in the media, suggests the public has a fundamental lack of trust in hospitals/health care and their ability to address complaints, and especially serious complaints like this one. This is precisely because there is a legislatively mandated lack of transparency. It’s not like hospitals want to treat patients shabbily, or think unethically (and possibly illegally) restraining patients is best practice, or don’t approach patient complaints with the necessary due weight. From experience, I can verify hospitals take all sentinel events extremely seriously, because we are, after all, in the business of making people better. I have no doubt that multiple various administrators at St. Joe’s are addressing the issue as I write. In short, time is needed for the appropriate investigations to be made.

I have to think, whatever the outcome, that this whole business was fundamentally a nursing issue. It could have been avoided. Basic Nursing 101: Avoid power struggles.  The nurses should have just let Mr. Meredith sit in his chair. Maybe that’s the ultimate takeaway.

Related articles

• Toronto man, 78, says he was injured by hospital staff (cbc.ca)

Labour Day and the Toronto Sun: An Annotation

Public sector workers are lazy and overpaid parasites sucking at the taxpayer teat. Or something. Please remember to tell us this when we’re doing ACLS on your sorry ass.

Happy Labour Day.

Love,

TorontoEmerg

Buskerfest

Where I was Thursday. I’m not very good at writing art review-style critiques using high-flown language, but I can say that I enjoyed Buskerfest a lot. There’s a bit of an edge to the performers. They generally live on the margins. They swear freely, even with children present. (O the horrors!) They’re tattooed and pierced, they are sometimes scruffy, and few are, to be a honest, a little creepy. The festival is not in anyway sanitized, which is why I think it is so successful. Some highlights:

Kate Mior. (Website.) One of the best we saw.

(Kate has already run afoul of His Worship the Mayor. According to Now:

Kate Mior has performed her mime-based living statue act for thousands of people all over the world, but she’ll never forget her encounter with Rob Ford.

Last year in Toronto, then-candidate Ford pushed through a crowd she was entertaining and then joked to everyone that she doesn’t pay her taxes.

“There is a certain stigma against street performers,” she acknowledges, “but in Toronto that’s changing.”)

Comment seems superfluous. More Kate:

Acrobats.

More acrobats.

This guy was quite good too. He had put some sort of shield or mask over his eyes to make them look mechanical. The effect was quite disconcerting.

But my favourite? HERE COME THE BUGS!!!

The bugs were great. We loved the bugs.

And no collection of bugs is complete without a Bug  master, who deserves special mention of his own

It’s a great festival, and if you’re downtown this weekend, check it out.

Snapshots of Nursing History

Courtesy of the National Archives of Canada.

Two nursing students from the John H. Stratford Hospital Training School for Nurses (later re-named the Brantford General Hospital School for Nurses). 1895

Nursing Students, bed making. Medicine Hat Regional Hospital. You get the notion the attentiveness is feigned. Making mitred corners is not that interesting.

Nurses at St. Michael's Hospital, Toronto. Three nurses, two nuns, a sterile tray. Note the (presumably sterile? clean?) wimples.

Nursing students being instructed in dietary science at the Hospital for Sick Children, Toronto.

Nursing students in a lecture theatre, Hospital for Sick Children. Note the instructor is in full nursing uniform: role modelling both behaviour and appearance --- deportment --- was considered a vital part of nursing education.

When psych nurses wore crisp white uniforms.

You Want a Side of Plavix with That?

Now that's good eatin'. Image via Wikipedia

Now arriving at the Canadian National Exhibition — wait for it — the doughnut cheeseburger*:

The Doughnut Burger made its debut at the Calgary Stampede, where brave revellers downed the sweet and salty snack, despite its high calorie count.

Now the hefty bacon cheeseburger with two maple-glazed doughnuts for buns will be featured at the CNE in Toronto.

The heart-stopping treat packs a walloping 1,500 calories and is sure to draw at least a few curious consumers.

The maple glazed doughnuts are a nice Canadian touch, eh?

Just for comparison, Micky D’s Big Mac (my guilty little secret) packs 704 calories, and a Harvey’s cheeseburger (Harvey’s is a Canadian burger chain) is a “mere” 460.

Can anyone explain the appeal of these? Is anyone actually tempted? I mean, if I’m going to consume empty calories, I think I would save them for something good.

__________

*Rather like the Lady’s Brunch Burger, sans egg.

So When Does This Become a Crisis?

I walked into the Emergency Department one hot morning a couple of weeks ago and found every last stretcher — twenty-five beds, including the two we try to reserve for trauma or codes — was filled with admitted patients; furthermore, five additional patients were waiting for consultants and likely admission. We were operating at 120% capacity even before the usual gamut of ED patients would begin flooding in.

Trying to manage an ED under these circumstances is like walking through an open field holding an umbrella during a thunderstorm. You know lightning is going to strike, and you hope like hell it doesn’t strike you. As charge nurse you start re-triaging the patients already under your management. Which admitted patients requiring cardiac monitoring can be safely parked in the hallway (in violation of fire codes) to make room for the syncopal vag bleed at triage? Which chest pain gets the last monitored bed? Is that MVC the paramedics rolling in nothing or a multisystem trauma?

And then, nurses providing care at the front-line begin to get frustrated and angry, because all of them chose to be ED nurses (as opposed to med-surg nurses), and they have lots of expensive education to validate their choice. In the event, they are helpless watching their elderly admits decompensating before their eyes.

Even more seriously, the sudden arrival of a trauma or a patient coding in the waiting room means a scramble to find room; in a scenario when seconds count, delay could be disastrous if there is no available bed to treat them. I don’t actually think the general public understands the fine line emergency department nurses and physicians walk between successful outcomes, where the patient is treated, made well, and discharged, and the morgue. Every health care professional in the ED practices with their heart in their throat and their licences over the fire.

So when does this become a crisis?

We’re told the principal cause of ED overcrowding is patients waiting for long-term care blocking acute-care beds. Not quite coincidentally the Toronto Star recently published an article about the appalling treatment an elderly woman received at the hands of a nursing home called Upper Canada Lodge in Niagara-on-the-Lake. The woman, named Sylvia Bailey, had a broken tibia which was left by nursing home staff untreated for twenty-three days.* She later died because of complications related to the fracture, and the case is now subject to a coroner’s inquest.

The two issues are not unrelated. Health care for seniors is vastly underfunded, and it’s reflected in both the number and quality of beds available. As a society we tend to give a lot of lip service to the care and support we give to seniors. In reality the frail elderly are at the bottom of the health care food chain. They aren’t glamorous or fashionable or have carefully managed public-relations campaigns associated with them. How many people do you see wearing a bracelet or ribbon for proper health care for seniors?

I tend to be quite cynical about this. The elephant in the room is that care for seniors is expensive, and no politician seems to be willing to state the obvious: provision of even adequate supports for a growing population of senior citizens is going to take a considerable mobilization of financial resources, i.e. increased taxes. Politicians love adopting seniors as a apple-pie issue. But given the current political climate which informs us we’re over-taxed, nurses are over-paid,and  the health car system is bloated, and throw in dodgy financial calculations by every provincial political party, any politician who tells you the case of Sylvia Bailey shall never be repeated, and ED wait times will magically disappear is flat-out lying.

So again, when do we decide this is a crisis?

__________

*College of Nurses of Ontario, are you listening?

Hotocalypse

Hot enough for ya?

For you non-metric types, that 38C is an even 100F. I think I speak for most of my fellow Canadians when I say, “WTF?”

I suppose it’s redundant and unnecessary to add that staying out of the sun, finding a cool, air-conditioned place to hole up in (if possible) and drinking plenty of fluids (alcohol or tea or coffee don’t count in this regard as they tend to dehydrate) is the best way to prevent heat exhaustion or stroke. I really don’t want to see you in my emergency all floppy, syncopal and dehydrated because you’ve decided Thursday is the best day to practice for the triathlon or because you think the lawn needs a little trim before the weekend.