In Our Own Words

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In Our Own Words: Medscape Nurses

Same blog, but we are in the process of moving to a new site. You can find new posts at:

http://blogs.medscape.com/nurses

 

Please check it out today.

How Does Your Workplace Treat RN Travelers?

As I watch the stock market plunge again today, I am hearing rumors of more and more local medical facilities letting their per diem nurses go, replacing them with RN travelers. Is this the right approach, considering the nursing crunch?

Throughout my career in various ICU settings I have met many nurse travelers, some quite knowledgeable, some well gifted; others could use a few classes in organizational and efficiency skills. But, all have been flexible in meeting the needs of the various units. Yet, speaking to them one-on-one, many believe that the nurses that they work with don't seem to recognize their abilities and skills. Nor do the managers. Some RN travelers feel like they are portrayed as incompetent in knowledge and skills.

I have found exactly the opposite. Many of the RN travelers one meets are exceptional nurses and interact with patients more so than the regular staff. This makes me feel a bit sad as many my colleagues see the traveler as a simply a  “body to take over the next shifts' patients,” without recognizing who they are, where they went to school,  their hobbies, interests, and why they chose travel nursing. It is not easy to acclimate to new setting every 13 weeks or so, but they do so in multiple, varied environments. So, why don't we take the time to get to know them and their accomplishments a bit better? 
 
How does your workplace treat RN travelers?

Change of Shift -- Video Version

Don't miss the latest report of nurse-related blog entries. Check it out here this week, at Crzegrl: Flight Nurse.

Are You Tending to Your Own Emotional Needs?

 How often do you leave your workplace drained physically and emotionally, especially after a hard day or night of work? I have slept the past two days -- I thought I would never complete my 3 shifts last week. All 3 shifts were racked with people with GI bleeding, an intubated 95-year-old frail woman, entering the last stage of life (without family support), and other patients whose families wanted “everything done for them,“ despite end-stage diagnoses …Is this what nursing has become today ? Keeping the dead alive?

I realize that is a rather blunt statement. I find these patients to be the most taxing emotionally, their families often making the provision of care even more difficult during a 12-hour shift. I left all 3 shifts emotionally drained. I felt I had done what I could for these patients. Yet, their families wanted more. What is “more,“ when a patient is attached to every modern medical device available to maintain life?

Feelings of turmoil ran through me as I climbed aboard the bus each morning. Sheer exhaustion…

At home, I climbed into bed, after stopping for breakfast at the local diner. I was going to sleep things off. Renew myself by reading a newly written biography on Einstein - 452 pages left to read and then window-shop for the rest of the week.  Until my next 3 shifts…what would they encompass?

What are your thoughts on compassion fatigue? How do you cope?

An interesting Web site: Compassion Fatigue Awareness Project

Imagine Working as a Nurse in 1889!

In New York, Columbus Square, the fall colors have not erupted to brilliant reds, yellows, and golds quite yet. Yet, everyone seems to be taking advantage of the 70 degree weather -- jogging, walking their dogs, strolling along 5th Avenue, and seeking hidden shopping deals at Bloomingdales. I just finished working a 3-day weekend, which wasn’t that bad although my body seems to be in a constant state of movement as my DBS battery has a lifetime of 5% left. Yikes!  I've noticed that lace seems to be making a comeback in clothing trends -- rather popular in the 1890s as well!

Can you imagine working in 1889 as a nurse? This list is a partial one of duties left to nurses of that time. (Wonder what physicians were doing?)  The list (Nurses' Duties were Different in 1889) starts out, "In addition to caring for your 50 patients, each nurse will follow these regulations:"

* Daily sweep and mop the floors of your ward, dust the patient's furniture and window sills. (Now called the Dept. of Housekeeping or Environmental Services!)
* Maintain an even temperature in your ward by bringing in a scuttle of coal for the day's business. (A responsibility of BioMedical Engineering!)
* The nurse's notes are important in aiding the physician's work. Make your pens carefully; you may whittle nibs to your individual taste. (Anyone know how you “whittle nibs”? I’m clueless!)
* Each nurse on day duty will report every day at 7 a.m. and leave at 8 p.m. except on the Sabbath on which day you will be off from noon to 2 p.m. (Does this refer to Ethnic origin and religious practices?)
* Graduate nurses in good standing with the director of nurses will be given an evening off each week for courting purposes or two evenings a week if you go to church regularly. (Ahh, a prerequisite required to maintain good standing…)

I find this list fascinating as it reflects how much nursing responsibilities and duties have changed over the past 100 years or so. While you may not remember back to 1889 (!), how about those of you who were practicing 30 or 40 years ago? What are the biggest differences you see?

 

ANA Supports Obama

My resourceful editor, Susan Yox, sent me information about ANA's support of the Obama/Biden ticket. They have developed a new Website, Nurses for Obama Biden.  Through this Website, you can find more information on ANA’s endorsement process and comparisons between Sen. Obama’s and Sen. McCain’s healthcare plans. You will also find a link to watch a video of Sen. Obama thanking the ANA for their endorsement! 

The very first link that I went to was the Obama Biden Marketplace for T-shirts, and other political ticket merchandise. Over the past few weeks, it seems to me that the issue of healthcare has been lost due to the volatile economy. I haven’t heard many answers to the current healthcare issues -- the uninsured, in particular, as I am one of them. It’s taken a backstage pass in the election. That worries me, since the economy is also reflected in healthcare delivery, quality, and accessibility to Americans. Correct?

Take a look at the views of both candidates regarding healthcare. How much can a $ 5000 dollar tax credit buy for you when it comes to medications, physician appointments, etc? Not much, as for me DBS programming costs more than $3600 per session.

What are your thoughts about the ANA supporting the Obama-Biden ticket?

Off-shift Nursing

The other day I had a conversation with a nursing supervisor about the night shift, working from 7 pm to 7 am. Our conversation became somewhat argumentative in the sense that we were both questioning if the quality of care delivered by nurses during the night shift drops significantly. It made me wonder ….

I have worked the night shift my entire nursing career. I could never return to the day shift. However, there are some issues that do occur during this shift. More often than not, I see my colleagues come in, plunk themselves down in their chairs by the nursing station and immediately focus on who is taking a break , “when, where, and how long.” At other times electronic documentation begins before even evaluating the patient. How can you assess a patient without ever seeing them? Aren’t you falsifying records or are you simply copying the previous shift’s entries? This worries me…

My shift begins the way I was taught in nursing school:  Seeing the patient, introducing myself, attending to their personal needs, performing a physical assessment, providing medications, and talking to families. Maybe this is no longer the way nursing is performed? Often my colleagues ask me to come and sit down, but there is too much to do for patients today.

Are there any evidence-based indicators to support off-shift nursing outcomes? What do you think? What differences do you see, one shift to another?

Do You Pray With Your Patients?

I have been having interesting online conversations with fellow patients diagnosed with dystonia about the use and effect of spirituality and faith on chronic disease and illness. Most of us with dystonia realize that a cure is a long way off, especially with NIH funding cuts. Personally, I don’t expect a cure for my dystonia during my lifetime. I expect only the reality of dealing with a complicated, complex, disorder marked by misfiring neurons of unknown origin!

I believe that healing prayer can be effective for physical issues, mental/emotional issues, and spiritual issues. Too often, people are looking for only the instantaneous and complete healings that Jesus performed. To be sure, those kinds of healings still occur today.  But they seem to be just as rare now as then. It’s more common to see gradual healing, often in conjunction with traditional healing methods like medicine, surgery, and counseling.  Just keep in mind that healing is the work of God, done by his will.  No one can control it.  We can only position ourselves -- or others -- to receive it, and then ask.  And we should not be surprised if we ask for one type of healing, such as physical, and receive another, such as spiritual.

However, I have never been asked by a patient or their family to pray with them in the ICU setting. Have you? This shouldn’t be a surprise for a simple reason.  Western medicine in particular has been relatively single-minded in its approach to healing, focusing primarily on the body -- and even just parts of the body -- for physical healing.  But as healthcare advances, a more holistic approach to healing is emerging. The relationship among body, mind, and spirit is becoming clearer. 

As the acuity of patients rises, will the use and power of prayer increase? Should we, as nurses, encourage the role of prayer in healing and comfort? What about our own beliefs? Do miracles occur in medicine today? I’d love to hear your thoughts on this topic.

Quote: "Find out about prayer.  Someone must find out about prayer." (Albert Einstein)

Related Resources
Primum non nocere (First, Do No Harm): Prayer, Culture, and Evidence-Based Practice

Intercessory Prayer for the Alleviation of Ill Health

The Final Debate

Phew... the final Presidential debate is over. I clung to every word each candidate said, but shut the TV off after the final statements, not knowing what had really been discussed. I did hear the word "healthcare" about 6 times from both candidates, however most of the debate focused on tax cuts, governmental spending, and the Wall Street crisis. I must admit that McCain looked angry at times and couldn't quite contain his facial expressions, bluntly directing them at his opponent, Obama, who remained cool, collected, and poised.

The post-debate coverage on TV went on till 12 midnight, past my bedtime; yet I have been glued to CNN’s “Best Political Team” since the start of the race 20 months ago. The polls are beginning to be released, answering the question "Who won?" Shouldn't we be asking "Is America going to win?"

And who is “Joe the Plumber” anyway? What about “Nancy the Nurse”? SIGH… Election fatigue now setting in...

What are your thoughts?

Hourly Rounding

I just read some  interesting articles about hourly nurse rounding. Hourly rounding was described as the nursing practice of regularly checking on patients' needs using the 4 Ps — positioning, personal needs, pain, and proximity of personal items such as the call light — with the promise to return in 1 hour. I recall performing hourly rounding on the night shift over 20 years ago when I was just beginning my career as a new, young, inexperienced graduate. It worked! At the time team nursing was also in vogue. I wonder if we need to return to this practice?

How many times have we found an unresponsive patient at 4 am, when we last saw them joking to us at 12 midnight? Our time now seems to be preoccupied with individualized care plans, transfers and admissions, bed shortages, and electronic documentation rather than actually visibly seeing our patients on an hourly basis.

Of course, a major difficulty is how to establish a work-day design that actually makes hourly rounding possible. This might be a particular problem with the nursing shortage today.

What are your thoughts on hourly rounding? Has your facility implemented this practice and how is it working? Should we return to this practice?

Articles
Collaboration Helps Hospitals Fine-Tune Hourly Rounding
Ring for the Nurse! Improving Call Light Management

Aging Hospital Buildings

A Canadian newspaper, the Globe and Mail,  released a news story on the infrastructure of aging, crumbling medical centers. They described several scenarios that sound all too familiar to us:

"Susan Hale's hospital bed in Joseph Brant Memorial Hospital's orthopedic wing is pushed against a corridor wall, squeezed between linen carts and orphaned equipment. Cleaning staff maneuver a wheeled garbage bin around Ms. Hale's IV pole. Visitors smile awkwardly as they pass, stepping sideway to avoid bumping the family members perched on the edge of her mattress.”

Sound familiar?

One of my best friends used to work in a large medical center in upstate NY, a Magnet-designated facility, and she told me that when their ER was too full, the staff would create patient rooms out of cleaning closets. Can you imagine being stuck in a closet for a 6-hour ER wait?

The gist of the Globe and Mail story was the increased outcome of deadly infections among patients within these crumbling walls. Almost all of the medical facilities within the immediate New York City area are aging. Paint peeling, mice scrambling, flies a-flying, tiles disintegrating, and garbage falling out of bins. Infections may very well be on the rise as we encounter more and more crumbing, aging infrastructures. Frightening, isn't it ?

Do you work in an old and disintegrating or over-crowded building? Have you noticed a rise in infections in your patients? If so, tell us about them.

Financial Fallout Coming to Healthcare Too?

Stocks, bonds, and savings -- those are the 3 big words being used by CNN News analysts today. The Stock Market plunged into a downward spiral earlier this week. Wall Street executives’ actions are being evaluated, as are their salaries. I must admit that I went to the bank earlier today just to see if all my financial assets were still there. They were!

Is the same fallout going to occur with healthcare institutions? The highest paid Hospital CEO in New York City is Herbert Pardes , with a yearly salary of 5.4 million dollars as of 2006, according to New York Presbyterian Medical Center. Next come the other major institutional CEOs at Mount Sinai and Sloan-Kettering.

Is the same financial fallout going to occur within the healthcare system as investments in new patient care centers, equipment, and personnel are made?

Anyone frightened about the events of this week? Will our jobs be affected?

Disorientation

“There is snow outside the kitchen door. It covers the deck in white sheets, unbroken except for the occasional paw print, and it cascades off the steps in thick, soft layers onto the pine trees in our backyard.” So begins the plight of a first year medical resident in upstate New York. Right away, I was reminded of my own backyard in upstate NY -- the massive snow in the winter and the pine trees that are next to our own house. Shoveling snow often preoccupies our time during long winters!

The journey described by the author  took me through his first day as an intern with the help of nurses during an on-call shift. He never would have made it without the assistance and knowledge of nurses. Ahhh -- how these young interns depend on us so much.  Some realize it immediately, others don’t realize it until their first medical error arises, and still others never realize the value of nurses during their entire residency (or their entire medical careers!).

Do you remember your first interaction with green, wide-eyed interns? Share your story with us! (Please alter any names and other identifying characteristics.)

Made in China

I just finished reading the book by Sara Bongiorni titled “A Year Without "Made in China": One Family's True Life Adventure in the Global Economy.”    The 227-page book describes how a family survived without buying “Made in China “labeled imports for an entire year -- 365 days. The author and her family decided to forgo Chinese factory made sneakers, sunglasses, nails, sheets, household goods, and more. The memoir is wildly humorous, but got me thinking about our economy, especially since watching the Beijing Olympic Games.

How much of the healthcare supplies we use – IV bags, supplies etc, are “Made in China” today?? Anyone ever wonder if they have seen "Made in China" labels on health equipment that we use on a daily basis? I never thought that a global issue like this would hit home. I began scrounging around within my own apartment for items that held the label “Made in China.” My forks did. My flower pots did. My towels held the same label. All "Made in China."

What next? Healthcare systems owned by China?

It’s Pulp Fiction Week at Change of Shift

You won't want to miss this edition of Change of Shift!

Joint Commission Rallies Against Nurse Bullying

I am in total surprise that the Joint Commission has decided to focus on nurse harassment and bullying, along with lateral violence in the workplace. We all know that it exists. But, is it the role of a national agency that accredits hospitals and care standards to address this ongoing, worsening problem? Is the Joint Commission going to create a standard of some sort? Will it really be effective in stopping lateral nurse violence? I don’t think so.

I do think  practicing nurses need to reassess  behavior towards our colleagues. We each are responsible for ourselves. If we can’t act compassionately to ourselves and colleagues, how can we be compassionate to our patients? And what about the role of nursing administrators in enforcing policies against discrimination, harassment, and lateral violence within staffs and units?

Should punitive disciplinary actions be taken against those nurses participating in lateral nurse harassment or violence? Should they be allowed to continue working as nurses? What are your thoughts?

The Joint Commission Sentinal Event Alert
Behaviors That Undermine a Culture of Safety

Who Tells a Patient’s Family That Their Loved One is Dying?

Imagine the following situation: You are assigned a 91-year-white female, admitted with urosepsis, requiring mechanical ventilation and intubation. Despite IV antibiotics, fevers jump through the roof along with climbing WBC counts and bands with a left shift. Within hours, Levophed is infusing at 60 cc/hr, NS is running wide-open, urine output stops flowing, and acrocyanosis arrives. Dopamine is added. Pitressin comes next. Soon you run out of electrical wall sockets as more inotropic drug support is added to sustain life.

The family hovers outside the door, without any sort of DNR discussion with the medical team. As the night wears on, the patient looks paler and paler, her cardiac rhythm now shows major ST depression leading way to a wide complex slow ventricular rhythm. By morning the patient’s systolic blood pressure is near 54/?, and she’s unresponsive as you provide oral care. Yet still the family "wants everything done." But there is nothing more to do. Palpable pulses barely exist. Mottling creeps along her limbs. There is no life.

The two residents seek to place a new arterial line instead of sitting down with the family to initiate a discussion about medical futility and comfort care. The nurse mumbles to the team, asking them to talk with the family about death and dying all night long, to no avail. The family continues to wonder in the hallway, hovering outside her room as her HR slowly begins to drop. They want dialysis now.

Still, no one talks to them about DNR options. No healthcare proxy exists. If you were in this situation, what would you have done? Does a nurse have the right to tell a family about DNR options or should it remain a discussion with the physicians?

Some related resources:

The Hardest News: Death Disclosure in the Emergency Department

The Last Hours of Living: Practical Advice for Clinicians

Choosing Quality vs Quantity of Life in Heart Failure: Decisions Often Made Early

Change of Shift Posts at Emergiblog

Check out the newest edition, just posted at Emergiblog.

How High Tech Must We Go in ICU Today?

Reading the latest news (360 Degree Care) about Sloan-Kettering’s newly developed ICU, I have one key question to ask -- how high tech must we go to give efficient care to patients today? Is rubberized flooring necessary? Do Web cams interfere in patient privacy? (Would you want to be seen weeping on a Web cam with your dying family member?) The article on Nurse.com describes how “Rooms have Web cams to let nurses monitor patients and beds that turn 360 degrees, perform respiratory percussion and vibration, turn and weigh patients, and elevate them to a chair position.” What happened to an aide and a nurse physically getting a patient out of bed, letting them dangle by the bedside, and then stand and walk to a chair?    
 
I have not seen this new ICU although there are constant advertisements, "Come Join Us," in nursing magazines for job positions in the unit. But I do like the idea of more room space; there never seems to be enough in any ICU. And I certainly like the concept that nurses had input in designing the unit architecturally. New beds, no manual chest percussion. My arms can get a rest now!

Has your critical unit been updated recently? What would your optimal ICU look like?

Will Hiring Foreign Nurses Solve the Nursing Shortage?

There is a bill being discussed in Congress, HR 5924, which focuses on providing employment-based visas for foreign-educated nurses. HR 5924 refers to the Emergency Nursing Supply Relief Act. The Act would allocate 60,000 visas for the next 3 years for nurses.

I’m not so sure how this will resolve the shortage long-term, as the bill ends in 2011. What then? I know one thing -- I’ll be ready to retire! The bill focuses on solving the current domestic problem of a lack of nurses. Seems to me that all of this is cyclical in nature.

Haven’t we done this before? Brought in Irish nurses? Brought in nurses from the Philippines? Do we need to do it again? What are your thoughts?

You can read more about this Act here