A forum to discuss the latest news and ideas in nursing and healthcare.
Friday, June 24, 2016
My relationships with numerous hospice patients over the years have usually been very amiable. I believe that there are several reasons that I'm able to establish good relationships with my patients. First and foremost is the fact that, in most cases, I am close to their age. I've experienced many of the things that they've experienced over our combined lifetimes. Even if we don't have much in common, most patients love to hear the story of how I ended up going to nursing school when I did. They're amazed that I graduated from nursing school when I was almost fifty.
I learned over the years that my tour of duty in the Marine Corps and my years in banking and construction present good topics for conversation. I've also lived in 25 cities in nine states over my lifetime. The benefit of all those moves is that I usually have something in common with my patients, even if it's only geography. Many times I've discovered that I've either lived in the city where my patient grew up or close enough to that city that we had still had plenty to talk about.
I also know hundreds of jokes and funny stories that many patients seem to relish. I've always believed that a good laugh is, in many cases, as therapeutic as medication. At least that's what some patients have told me. But the crown jewel of my non-medical interventions is my magic tricks! Or at least I thought so--until I met Bill.
Bill, 68, was a very dignified gentleman who had been, up to his admission to our hospice program, an exceptionally successful entrepreneur with interests in everything from stocks, bonds, and real estate to medical equipment and manufacturing. When I met him he was well known, highly respected, and terminally ill.
He had a hard time accepting his diagnosis, and had a reputation for being hostile to his caretakers. During visits, Bill would be silent or quite gruff, depending on the day. Caretakers reported that Bill would resist any suggestion that might make his journey easier. Because of this, my initial nursing visit was short--to say the least! His wife was very apologetic and made excuses for his behavior, assuring me that it was not personal. I assured her that I didn't take it personally and that I looked forward to future visits, confident that my various interventions would eventually help us build rapport. They'd helped so often in the past I trusted that they would in Bill's case.
I visited and assessed Bill a couple of times a week in his home without establishing any type of relationship with him. His wife continued to be glad to see me, but Bill was unchanged. His pain was well managed and his wife stated that he didn't appear overly anxious. I began to suspect that he was simply furious that his life was coming to a rapid end and there was absolutely nothing that he could do about it. It wasn't in his character to be powerless.
On one visit, I tried a couple of my best jokes, neither of which got any response from him. On another visit I told a funny story about my past, but Bill just sat in his hospital bed and a stared at me. I suspected that he was thinking that here he was, a powerful businessman, having to stay in bed and listen to some nurse tell stupid anecdotes about his insignificant past. That was the moment when I decided to reach into my bag of magic tricks.
My collection of magic tricks is very elementary, really simple, and doesn't require any significant props or special devices. I call them "pocket tricks" because I carry what I need to perform the tricks in my pocket. I can make a tissue disappear and reappear in the palm of my hand. I love turning a dollar bill into a twenty dollar bill right before my patient's eyes. And I always enjoy making a penny disappear only to find it in my patient's ear…that trick always goes over well with children!
I elected to begin my magic show with my most baffling pocket trick: the vanishing tissue. I got Bill's attention and completed the trick without a flaw. The tissue disappeared and miraculously reappeared, seemingly from thin air. I looked at Bill for a reaction, and noticed that his face was unchanged. Suddenly, he yelled, "How dare you come to my home and show me a trick that I learned in the seventh grade!"
The bedroom became quiet. I said, "Look, Bill, I'm willing to try whatever it takes to help you feel better, even if that includes doing junior high magic tricks." Bill began laughing like I've never heard anyone laugh before. His wife came into the room, and we stood watching him laugh until tears started to roll down his cheeks. He finally regained control of himself, looked straight into my eyes and said, "That's enough for today, but you better have a better trick when you come back to see me!"
I assured him that I would, and departed for the day.
I discovered on my next visit that the disappearing tissue had broken the ice and allowed Bill and me to talk about the things we had in common. Our experiences early in life were very similar, much more so than I had ever expected. He'd even tried to enlist in the Marines, but failed because he had flat feet!
It took a while, but we became friends. I believe that I laughed more with Bill over the final 3 weeks of his life than I have laughed with any other patient. And now, I always smile when I perform a pocket trick, because it reminds me of my friend Bill.
Samuel Franklin Engs, BSN, RN, is a hospice nurse in Lake Mary, Fla.
Tuesday, March 1, 2016
“The ED is full of people who shouldn't be there. That's why the wait is so long.”
I've heard many iterations of that sentiment from patients, visitors, the general public, politicians, and even healthcare professionals more times than I care to count in my 30-plus years in emergency services.In my early days as an emergency nurse, I witnessed coworkers show obvious disdain when patients came to the ED with chief complaints that didn't fit their definition of an emergency. Unchecked, those attitudes were contagious and toxic.
Fast-forward many years, and I gained a new perspective as an emergency nurse leader with elderly parents and in-laws. Frequent ED visits became a reality. My family members' fragile health conditions rapidly worsened if their infections and other concerning symptoms weren't evaluated and managed quickly and aggressively. They simply couldn't wait for an office appointment.
I'd like to set the record straight: Our ED population represents people in need. The definition of emergency is personal, especially for those who are scared, in pain, or lack healthcare knowledge. When you have a garden-variety UTI and can't access timely care because of personal circumstances, you seek relief ASAP. Urgent care centers and medical aid units can be good options, but many aren't open 24/7, have limited capabilities, and expect payment up front, which all pose barriers.
What about “drug seekers” and challenging patients with behavioral health issues? Granted, the ED may not be the best place for them—but with the right systems in place, we can try to connect them to the services that they need.ED crowding is a complex problem with roots in the availability of health services in a particular community, care management systems, financial resources, public expectations for instant access, and many other factors. We need to stop blaming patients and focus on tangible, systemwide improvements. Many view ED care as expensive, but preventable harm from lack of timely access to that care carries a much higher price.
The ED is a safety net. No, it can't be all things to all people, but like the Statue of Liberty, it stands ready to help those in need: “Give me your tired, your poor, your huddled masses, yearning to breathe free...”.
Tuesday, November 24, 2015
The irony of nurses reporting to work while sick is obvious. Nurses are responsible for healing, not spreading infections. Presenteeism is a problem that runs deep within the healthcare community. The constant exposure to infection, stress, and fatigue lead to one almost inescapable outcome: the dreaded sick day.
A recent study from JAMA Pediatrics conducted a mixed-methods analysis of more than 500 clinicians and their self-report on presenteeism. Of those surveyed, more than 95% demonstrated the knowledge that working while sick puts patients at risk. Despite this knowledge, 83% reported working despite illness at least once that year. They didn’t want to let down their colleagues, create staffing problems, or disappoint their patients.1 However, the study conclusions show that the issue is more complex; presenteeism is shaped by sociocultural factors (peer pressure) and systems-level factors (facility policy).
Culturally, nurses are educated to work as a team, care deeply about their patients, and value their job. However, we must realize that in the long run, we are undermining all three by coming to work sick. At a systems level, attendance policies meant to assure that adequate staff are present to care for patients may inadvertently encourage presenteeism at the wrong time. This situation is especially true for those staff who push the limits on calling out sick when perhaps they really aren’t, and subsequently ride the fence on their sick time limits. Loss of income also may be an underlying reason for presenteeism-- depending on their employment status, some nurses may not get paid when they take sick time.
As the JAMA study points out, nurses and physicians hold themselves accountable for providing quality care. In the grand scheme, very few clinicians actually abuse sick days, but all too often nurses are caught between justifying their illness and endangering patients. This ethical dilemma is a difficult one, but we should err on the side of safety for our patients and ourselves by staying home. Until nurses and organizations come together to eliminate the root causes of presenteeism, we will continue to see a cycle of illness perpetuated among patients, colleagues, and professionals.
1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-21.
Monday, November 16, 2015
Flu season is ramping up. It’s a good time to cover a topic that should be second nature to all of us, but unfortunately still poses significant challenges: adherence to best practices for infection control. Research shows that while most nurses overrate their own compliance with respiratory and hand hygiene practices, they observe their colleagues practicing good hygiene less than 3/4 of the time,1 and actual compliance rates appear to be much lower; one recent study of triage nurses put median objective compliance with respiratory hygiene measures at just 22%.2
These statistics can have a very tangible and concerning impact on our patients. If a nurse accidentally infects a patient, he or she may not be aware of the long-term repercussions, since lengths of stay may be short and incubation periods vary over a period of days. Whether it’s influenza, HAIs, MRSA, or C. difficile, the simplest hygiene processes make a difference. There certainly may be human factors and workplace design barriers that are obstacles to compliance in certain work settings or environments; these are areas of much needed focus and effective intervention.
Standard precautions, PPE, infection control-- although the principles remain the same, methodologies change constantly with advances in education, research, and equipment. It’s essential to consult your facility’s infection control policies or guidelines whenever necessary to make sure you are protecting yourself, your co-workers and other patients. When it comes to the basics, such as hand and respiratory hygiene, we all need to consistently renew our commitment to what may seem to some inconsequential, routine, and even occasionally burdensome.
So this winter, let’s make a dedicated (re)commitment. Cover your mouth and nose when sneezing or coughing. Cleanse your hands frequently, including before and after every patient encounter. Apply warm water before soap. Recognize that alcohol-based rubs have their limitations (they don’t kill C. difficile), but do use them as an adjunct to handwashing. Know the risks of artificial fingernails and don’t apply them if you work in direct patient care—they can harbor pathogens that may not be eliminated by standard hand hygiene practices.
Refer to your facility policies on infection control, including the proper use of PPE. Educate yourself and empower your colleagues. Make sure posters and visual cues are prominently displayed. Read up on the latest guidelines from the CDC, INS, and IHI.3 In fact, use as many approaches as you can think of-- research suggests that a multimodal method is best for increasing and maintaining hand hygiene compliance rates due to the complex environments in which we practice.4
What are your successes and challenges in maintaining proper infection control practices in your work setting? Post a comment below and let’s keep the conversation going!
1. Delahanty KM, Myers FE. Nursing2007 infection control survey report. Nursing. 2007;37(6):28-36.
2. Martel J, Bui-Xuan EF, Carreau AM, et al. Respiratory hygiene in emergency departments: compliance, beliefs, and perceptions. Am J Infect Control. 2013 Jan;41(1):14-8.
3. CDC. Respiratory Hygiene/Cough Etiquette in Healthcare Settings. 2012. http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
4. Hebert J. Improving hand hygiene through a multimodal approach. Nurs Manage. 2015 Nov;46(11):27-30.
Monday, November 9, 2015
In October, the journal of Anesthesiology published results from a study conducted at Mass General Hospital on perioperative medication errors. Researchers found that every second operation resulted in a medication error (ME) and/or an adverse drug event (ADR). Sadly, more than one third of these errors led to observed patient harm. 1 These numbers are stunningly different from existing data on the subject, which is sparse and largely self-reported. However, these numbers are likely much closer to the true impact of ME’s and ADE’s.
Although we know the OR environment is a completely different animal than the settings most of us work in, I think there are some lessons to be learned here. How can we take this sobering information and use it to evaluate and improve patient safety across all settings?
First, honesty is paramount. Until the healthcare community can accurately track and identify patient harm, we’ll never reach optimum patient safety. Meticulously recognizing risk, documenting care, and avoiding error is part of our working lives; we follow best practices, advocate for our patients, and learn from our mistakes.
The next time the opportunity comes to participate in a new initiative or implement a new tracking method that supports patient safety in your facility, I hope that nurses will fully engage. Too often, we are slow to change as a healthcare industry, or we must overcome barriers to best practices in the real-world setting. In all cases, we can continue to embrace with enthusiasm what nurses do best—patient advocacy, caregiving with integrity, innovation, education, and documentation.
I applaud the researchers for uncovering such important information. It may be a small step, but it’s a step in the right direction, and I hope that clinicians take note and take action to actively participate in future efforts to improve patient safety, regardless of their setting.
1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2015.