Nursing Influence

As a nurse it’s weird to be a patient yourself. So far, I’ve been lucky that I haven’t been hospitalized for anything major during my nursing career. But, as I was recently a patient in the emergency room, I was able to see things from the eyes of a patient.

I went through triage, and with my abdominal pain, I was very low priority. So, I sat in the waiting room for about 2 hours before ever being put in a gown and being seen by a physician. The doc came in and did an assessment, ordered some IV fluids, a GI cocktail, and an abdominal ultrasound. The nurse came through for the IV and the delicious elixir, and transport later came through to to take me to ultrasound. After my ultrasound, my gurney was placed in the hallway as there were no curtained beds available (my least favorite part of being a patient in the ER).

I never felt like I was being rushed through the process or that people weren’t listening to me, but I did feel like it would be easy to get lost in the shuffle. As one health care employee came to speak to me, they had no contact with the other health care workers nor did they acknowledge each other. Every person had their own job and they each did their job right on queue. As a patient though, it felt very automated; I never talked to one person for more than 60 seconds at a time and since the nurse was writing her notes on a crumpled piece of paper from her pocket and the doc walked away without writing a single thing, I didn’t really feel like everything I was telling them was being taken in.

But, now from the other side of the coin, I can understand not writing down pieces of information. I’ll often take a history from a family member without writing things down or having the computer open if they have a minimal amount of previous medical problems. I’m not an ER nurse and I never have had that experience, but I assume that they have several patients at the same time, especially in the sub-acute section of the ER (like where I was located) and aren’t able to take the time and sit and talk.

This does make me look at my practice a little differently. As I admit a patient into the ICU, I take a couple extra minutes to explain the plan and ask them if they have any questions. If I can, I will tell them that I need to call the physician to get some orders, but I expect to go for a CT scan that afternoon and have some blood drawn in the next hour. Knowing what the plan is and who might be coming to see them takes away a lot of the automation of health care and gives them a constant person (me) to talk to if they have concerns or questions.

Giving bad news to patients or their families is always hard… but when they refuse to listen, it makes it even harder.

“Mrs. Smith, when your husband collapsed at work, his heart had stopped beating. We know that his brain went without oxygen for at least 10 minutes, the length of time it took the paramedics to get to him, in addition to the amount of time it took his coworker to find him. While they were able to get his heart restarted, there is no way to repair the damage done to his brain. After 48 hours, he has not woken up or shown any signs of responsiveness. All of the tests we have done to his brain have shown that it is not functioning – he is brain dead.”

After a member of the healthcare team gives grave news like this, the response sometimes goes like this:
“Oh look at that! *points outside at the helicopter pad* When Mr Smith was little, he used to live near a small airport where all of these planes and helicopters used to fly in and out. I’m sure this is a very peaceful sleep for him. He’s always been such a fighter.”

A response like this makes you wonder if they were actually listening to what you were saying, or if they’re just using avoidance as a defense mechanism. I have compassion for people who are dealing with one of the hardest events in their lifetime like this, I really do, but I wish it was easier for people to open up their eyes to reality.

How do you handle these situations?

As I watch the nursing students come through the ICU each semester, I’m seeing a big change in attitude… and not for the better. As I went through nursing school, we had very strict rules impressed upon us by our instructors- our uniforms were to be ironed, we were to stay out of the nurses’ way (i.e. don’t take their computers or chairs), and we were to prepare for the day by studying the assigned patient’s condition and pertinent labs and medications. And, I’m not talking 40 years ago… I’m taking 4 years ago.

We had one particular nursing school come through our unit in rotation this fall and I was disheartened by each and every student I met from this school. I had one student who was assigned to my patient. She came in that morning (and was late and we were already halfway through shift report), she did not know what CHF, congestive heart failure, was nor how it is treated… and this was the patient’s diagnosis. We had morning medications to give and the student said “I dont know” when asked about each of the 3 medications we were giving. I asked her to look up the medications and come back to me with the pertinent information and she stood there for a moment, then came over to me and said “I dont have a book”, I told her that there were online resources as well as several books in our medication room. Next, we had to take this intubated patient down for a CT scan and upon our arrival to the unit, I hooked the patient’s cardiac leads to the monitor and I asked the student to hook up the blood pressure cuff and pulse oximeter (finger probe). After taking a phone call, I came back into the room and the student was holding the blood pressure cuff in her hand and said “I can’t figure out how this goes on”. That’s it. I was mentally checked-out as a teacher.

This woman (and I say woman because she was about 35 years old) was going to graduate, potentially, from nursing school in just a few months. Upon probing her to get a better idea of her clinical experience, she told me that she has been an LPN for years, but has never actually worked. She got divorced, gets a large alimony sum, and just needed something to do to get out of the house while her kids were at school, which is why she went to nursing school. Students just don’t seem to care. They went into nursing school because they heard it was an easy road to a good salary. But, now after being on a waiting list to get into nursing school for a year, and being about ready to graduate, the market has turned around and hospitals are not hiring new graduate nurses (things will change, and they can easily get experience in LTC for a year and then apply for whatever their “dream job” is).

Throughout my posts, I keep going back to the topic of professionalism. I think that is huge for nursing. If we as a group show that we deserve to be treated with respect, then we will be. This is a big topic that seems to be missing in nursing education. What could we do as hospital-based preceptors to get this message across to students that we only see during a one-day shift?

I subscribe to several nursing journals, one of which is “Critical Care Nurse” – published through the AACN (American Association of Critical Care Nurses) and I really do try my best to read all of the articles in each one, but honestly, only get time to skim through the magazine and read the articles that pertain directly to my career or articles where the title catches my eye.

Every once in awhile an article comes along that I love. Heck, I’ve even been known to rip out an article and put it in the nurses’ lounge at the hospital a time or two. In September 2009, they published an article titled “Patients’ Perceptions of Nurses’ Skill” which I read and loved. The article discusses the factors that our patients use to assess our skill level. How do the factors that they use differ from the factors you use to look at your own nursing skill, or the skill of your coworkers?

Nursing practice has three domains that make up skill: interpersonal, critical thinking, and technical. Which of these can our patients most easily pick up on? Interpersonal, of course. Our patients have very little insight into our critical thinking skills. As they lay in bed trying to breathe post-extubation with stridor, they don’t know that you’re the one calling the doctor for racemic epi, IV steroids, and heliox because you know the cause of the stridor. The same is true with our technical skills. Sure, they see us removing their central line, but they don’t know correct steps to tell if you’re performing the procedure in conjunction with best practice standards. All that our patients can see is our attitude about these things. When you call the physician on your patient with respiratory stridor, they see that you are doing this quickly and with confidence. You are in the room reassuring them that things will be okay and educating them on what is happening. When you are pulling the central line, you are explaining each step to the patient to reduce their stress level about the procedure and possibly chatting about another topic to get their mind off of it and show interest in them as a person.

I highly suggest reading the article (I’ve attached the PDF below), but the big take-aways for me were:

• Patients describe the attributes of skilled nurses as: friendly, caring, compassionate, kind, good listener, confident, enjoyed his/her job, well-organized, and followed through with tasks he/she said they would do
• Patients describe the attributes of a non-skilled nurse as: Lack of confidence, timidity, rudeness, abrupt answers to questions, indecisiveness, frustration, and a negative attitude

So, I look at these terms that our patients use to decipher our nursing skill and I can see the affect on our unit. There are a certain group of nurses who often get thank you cards or small tokens of appreciation from patients and family members and they display off of the attributes of skilled nurses – seems that this article is telling the truth :)

This article helps me remind myself when my day is going horribly, to take a breath. You’re getting paid to be at work and these patients/families are going through a hard time right now. Relax and do your job, they don’t need to know that you just got chewed out by a jerk physician or that the patient next door is confused, crawling out of bed, and on your last nerve. When you go in the room to do something, do it with a smile and take the extra time to try and make a connection with each one of your patients. You will stand out as they remember their hospital stay and you will personally feel better for having a relaxed attitude.

Patients’ Perceptions of Nurses’ Skill – Critical Care Nurse

I don’t know where it comes from, but most doctors seem to have lost the concept of patient privacy. Doctors are quick to walk in on patients using the bathroom, despite being told by the nursing staff that the patient is unclothed. Or, they will do an assessment on a patient (including pulling their gown up to their head) without closing the curtain first – and our doors are big glass walls.

We had an extreme example of this happen to us awhile back. We received a patient who went emergently to the cath lab with an acute MI (heart attack). He came to us in the ICU with his femoral sheaths still in place and was unable to urinate while laying flat in the bed. So, the nurse was in the room getting ready to place a foley catheter in his bladder which left the patient without any covering over his lower half as she was prepping his with iodine to sterilize and prevent infection. Little did the nurse know, the patient’s physician was in the next room speaking to another patient’s family members about the Steelers (which happened to be both of their favorite football team). The physician then decided to take these family members to meet his patient next door, who was also a Steelers fan. The physician pulled the curtain wide open, exposing the half naked patient and without a second thought started talking about football. The nurse, who had sterile gloves on, started saying something along the lines of “You need to get out. We’re in the middle of a procedure” and the physician kept talking over her. She then took off her gloves and pulled the curtain closed again in front of his face and the physician started screaming for the charge nurse because of the nurse’s “attitude”.

If I were that nurse, I think I would have had a hard time keeping my cool in front of the vulnerable patient, the idiot physician, and the family members who got pulled into this awkward situation. And, even after speaking to the charge nurse and the nurse involved, the physician still insisted that he did nothing wrong and the nurse needed an “attitude adjustment”.

Whew.

I can’t even explain how busy we’ve been at the hospital over the last two weeks – our ICU has 28 beds (although only 26 are currently usable due to the last 2 being used by another department during our oh-so-close-to-being-finished renovation). I worked just after New Year’s and we had about 14 patients in the ICU, which is pretty typical for us in non-SnowBird season. Just two days ago, we had 26 patients occupying our 26 available beds. Insane.

For those of you who may not be familiar, “snowbird” is our loving term for those in the elderly population who live in a warm climate for the winter and return to their northern/midwest home when the temperature is more tolerable there (and less tolerable during Phoenix summers). The exact times that the snowbirds arrive in Phoenix varies each year… sometimes we get busy in December if the snows are intense in other parts of the continent and other times we don’t start getting busy until after they have celebrated the new year with their children and grandchildren. Then, the snowbirds usually start to head back home in April or May, again depending on the weather where ever “home” is for them.

So, we’ve officially been hit with snowbird fever. I don’t know what it is, but it seems that people get out here every year and get hit with unplanned illness. Maybe it’s the stress of the holiday season or the stress of packing up and moving across the country? I’m honestly not sure. But, this year, I’ve noticed an especially large number of unexpected admissions- ruptured AAAs (abdominal aortic anneurisms, where the aorta ruptures and the patient is bleeding out into their belly), ruptures esophagus (esophagus ruptures, leaving the patient unable to breathe and emptying stomach contents into the chest cavity), and massive heart attacks leaving the body systems nearly useless. We have a high percentage of patients on dialysis (meaning they have kidney failure), which attests to the overall acuity of our unit right now.

I’m wondering if this is a downward trend in the health of our country, or perhaps a sign of the times with less people getting preventative health care. Hmmmm?

Stay healthy, Phoenix.

I made one of those mistakes that your mom always warns you against… judging a book by it’s cover. Being a nurse, it’s so easy to generalize having seen all the sights that we’ve seen. You get report on your patient who’s a smoker and threatening to leave the ER to get a cigarette (but is still being admitted as an inpatient) and you assume it’s going to be a long, argument-filled day of why she cannot just simply “step outside for a smoke”. Or, you hear in report that your patient’s tox screen was positive for cocaine and he just had a heart attack…at 30 years old. It’s sometimes very hard to have compassion for those people who have brought their medical problems on themselves while in the next bed, a sweet 72 year old is hanging on to her life without doing a single thing to harm her body (and generally the non-drug user is a lot kinder to the staff and easier to get along with for 12 hours straight).

I was at work recently, and my morning started off with one patient who had surgery the day prior and my other room was the open bed (meaning that I was the nurse open to take the emergent patient from the emergency room or the patient who was coding on the other floor). My surgical patient wasn’t doing too well- her morning xray showed that her left lung was whited out (which in her case meant that she had blood around that lung) and she needed a chest tube placed to drain the blood. So, the surgeon came in, and it took him several attempts to get the tube in because the patient had a lot of scar tissue around her lung due to a previous lung surgery and about half of a liter of blood ended up on the bed. At the same time as we were cleaning up the mess, the charge nurse came in to let me know that I was getting a patient who came in from the emergency room and I needed to call and get report. So, that was already a bad start to hearing about the patient- I was about 2 hours behind in caring for my first patient and now I had another one to admit.

So, I call down and get report from the nurse, who starts by telling me that this patient is HIV+, has hepatitis, herpes, is a current smoker, and they just had to sedate because he was screaming and rolling all over the bed. Awesome. If this doesn’t sound like a winning assignment, I don’t know what does. *sarcasm*

The patient gets to the unit, is indeed restless and complaining of a lot of pain (and in my head I’m wondering if he’s a drug user too because of the other history I had heard). So, I give him morphine and he actually sleeps for a few hours. This is the definition of nursing bliss. :)

After he wakes up, I had all of his HIV medication (that we had to have couriers pick up from other hospitals in the valley because they are so hard to come by and expensive). I got him a sandwich from the kitchen and we started talking – he was very calm and relaxed now. He told me about his past – he was a professional figure skater and lost his partner about a year ago to heart failure and has been having a rough time ever since. He had a dog at home that he was worried about because he didn’t have anyone to go feed the dog while he was in the hospital (our direct of social services ended up taking the patient’s keys and going to get his dog, with his permission of course). We talked for almost an hour and he was one of the sweetest people I had come across in awhile.

I wish that I could curb my judgments about people more easily. I was dreading my day in the morning and as I left work that evening, I had a smile on my face. It was a good day.