eric135

NASCAR 1: Planned Parenthood 0, What if nurses got paid per patient instead of by the hour, Culling our Platys...

• I read on the internets that the House voted out Planned Parenthood, and is continuing to fund NASCAR. What's that all about? I've never been much for either -- parenthood or NASCAR -- but how have our priorities gotten so effed up? I personally don't consider NASCAR a "sport" per se, although yes it does take some skill -- right up until you run up against a RIGHT turn -- but, hell, the only way I'd get into it is if they required the drivers to txt while they drove, or if the audience got to throw obstacles randomly into the road.
• I wonder how much health care would get fixed if nurses got paid via capitation (per patient) rather than by the hour, or if physicians got paid by the hour instead of by capitation. I mean, let's just say a nurse is paid $30 bucks an hour for a 12 hour shift for taking care of five patients. That comes out to $72 bucks per patient. I wonder, as much as we nurses do belly-ache about patient safety and all that, how many of us would take another patient (or more) to get another $72 (or more) a shift. More interestingly, I wonder how many of us would choose to get $72 per shift less in order to be assigned one patient less? I'm totally not saying we should do this, but I wonder how the discussion would change, if it would change at all?
•  We just had to thin our population of platys in our 10-gallon fish tank. We started out with several species of fish, but over the past couple of years, everyone died out except for these Platys. They just kept breeding, and at this point there must have been 70 fish (most of them juvenile) in the tank (along with one bad-tempered Beta that probably hates kids). We looked it up on the internets, and it seems one of the more humane ways to euthanize tropical fish is to drop them into ice water (actually the most humane methods were clove oil or a fish anesthetic called MS-222 or alcohol -- we had none of these). But it still felt strange catching 10-15 baby fish and dropping them in a bucket of ice water. A bit traumatizing, considering how much heartache we go through when our goldfish die.
• I have been playing iTunes, and for whatever hellish reason, I keep playing the theme song from The Sound of Music over and over...

Admit Nurse Moments

 

 

[ME] OK, so I'm going to ask you a few questions about the medications you take every day.

[PATIENT] (exasperated sigh) I wrote all that down so you won't have to ask me again.

[ME] Your typed list is great, but I'd like to go over the meds individually, for your safety.

[PATIENT] I know, you guys ask me the same thing every time, that's why I typed it all out, so I don't have to repeat myself over and over. Can't you just read the list?

[ME] OK, so... you're saying this list is complete, and that you are taking these doses, and that you haven't changed your medications or your doses since you typed this?

[PATIENT] Of course it's right... I wouldn't have spent all that time and energy typing all that and then print it out if it wasn't right... I mean, dammit, how many god-damm times do I have to repeat the same things over and over? Just read the list for Christ sake...

[ME] Well, just for laughs, let me just go over the first one with you... is that OK?  I know it's probably all correct, but let's just see, is that ok? Let's take a look-see at this here list... Ah, the first one here... Pepcid, you take Pepcid 20mg once a day, right?

[PATIENT] Oh God no, I haven't taken Pepcid in MONTHS...

[ME] … … ...

...of the myriad verbal and written reprimands that I have written over the past four years, it turns out that I have written up three times as many male workers as female workers.

I don't know why write-ups are on my mind of late.

One of my co-workers was talking about write-ups on our unit, and she told me that I was "known for being more lenient when disciplining males, but am more knit-picky toward females."

Well, as a leader, I am well aware of the fact that some folks have perceptions that I can't help them with. But this one sort of hit home, because in my business, there are more females than males and I always strive to be fair. So when faced with this criticism, I of course went back and looked it up.

As it turns out, of the myriad verbal and written reprimands that I have written over the past four years, it turns out that I have written up three times as many male workers as female workers.

Which puzzles me even further. I mean, given our demographics, I really should be writing up females about four to five times more often than males, but for whatever reason that isn't happening.

And contrary to the opinion of that coworker I mentioned at the beginning of my post, one of the men I gave a written warning to wrote a letter to the clinical director that I personally had a bad attitude toward him because he was an older male with grey hair (which really shocked me given that I was, even then, 75% grey myself).

What seems to piss me off, possibly on a sexually biased level:

• I obviously don't like foul language. Although I am relatively tolerant of "casual" profanity, I have a peculiar distaste for profanity that is yelled or spoken in anger.

What I seem to discipline evenly across the sexes:

• I don't like it when folks disobey the chain of command (some of my write-ups were for workers from other departments that were rude to my staff instead of coming to me with problems).
• I don't like it when folks make patients feel guilty or bad for being sick (that just gets my gall considering what industry we are in and how we are paid for a living).
• I don't like it when folks go to another charge nurse when I've already told them "no".

Interesting... Something to keep in mind for the next appraisal year...

Maybe knowing what we look like down the sights of loaded shotguns is an ideal way to get to know your boss?

I rarely get written up. No, really, it just doesn't happen very often. Of the handful of times I've gotten a write up, it almost always has been due to by absences (we get in trouble after the 6th absence in any 12-month period, and the trouble gets very serious at 9 absences a year). But having a history of kidney stones, I have always had a straight-forward attitude about my attendance: I do the best that I can, and I try to make up for it by doing other things (I worked a total of 24 extra shifts in 2008, plus a lot of extra "projects" for the unit).

So it came as a surprise when the interim clinical director asked me to meet her in her office.

I had assumed it was to be introduced to the new permanent clinical director, but I realized pretty quickly that the tone of the meeting was serious.

The exact details of the write-up are not all that noteworthy, in that, like almost every other employee I have ever had to write up for this infraction or that, I refuted the factual basis (and even questioned the truthfulness of the interim clinical director). Most of the complaints were that I simply didn't like the interim CD and tended to make that pretty obvious in our daily interactions.

Suffice it to say that I made the decision to live with the write-up and work toward building a relationship with the new clinical director. I decided, after a few days of thought, that it was more important to move on to the bigger problems of two inpatient units that had been through more than a year of hell, and needed to get over all of the conflict and just move on.

It was a good decision, in retrospect. It has been five months since that write-up day, and the new clinical director and I have forged a good professional relationship, despite the fact that we have both, literally, seen each other from the business end of a loaded shotgun (the write up meeting took 90 minutes -- I've never had a write up meeting that lasted that long, with basically me arguing with two clinical directors -- much of the meeting was heated and even mean-spirited, myself included). We've been able to work together on several projects, and I've come to trust her judgment and her sense of fairness and justice.

Maybe that initial meeting -- little ol' me seated on one side of a wide desk with two "bosses" taking turns arguing one point after another -- helped me get to this point faster than my peers. Nurses on my units are amazed at how quickly I "turned around," from considering to resign to becoming a real partner in difficult times. Of all of the charge nurses, I have become the new CD's main supporter.

Maybe knowing what we look like down the sights of loaded shotguns is an ideal way to get to know your boss?

A meeting with Jean Watson... 2 stars out of 4...

Jean Watson spoke at our hospital the other day.

I had worked the night before, and my shift ended at about 0630am, but the meeting wasn't scheduled until 8a. So I spent more than an hour sitting in my car, parked in the employee parking deck, watching Rachel Maddow shows on my iPod.

The meeting was packed, with about 50 nurses attending. All of us were either charge nurses or clinical directors with a few clinical educators mixed in.

I think Jean Watson thought all of us were well-versed in her theory, and that everyone in the room was accustomed to the spiritual, metaphysical and existential nature of her work. I don't think she realized that very few of the nurses attending were very familiar with her book. Thus it surprised me when, with very little by way of introduction or preparation, she proceeded with a meditation exercise. She brought out a "singing bowl" very similar to the one pictured here, and she rubbed the rim with the stick which caused the bowl to resonate.

I've never been very good with meditation. I've tried several times to meditate and I just can't do it. So while everone else in the room bowed their heads and closed their eyes, I started to get a serious case of... the giggles.

To stop myself, I started calculating the Fibonacci sequence of numbers in my head.

Not a great beginning.

It's not that I don't believe in the theory. I do think it is important to appreciate our patients as a total, unique, spiritual, significant human being, and not simply a machine. That's something I can get behind.

But I was sort of hoping the meeting would be more of a "hands on" session, with all of us charge nurses discussing how to actually use the theory.

• What specific behaviors would be seen when observing a nurse that is well versed in the theory?
• What sort of verbalizations should be used? In other words, what needs to be said?
• How do you document use of this theory?
• How do you use the theory if your background and comfort zone is more scientific / numerical / logical / empirical?
• As a charge nurse, with scientific background/personality, how can I teach or model this theory for my nurses?

We didn't really go into that at the meeting. In fact, at one point, one of the nurses finally simply asked Jean Watson to go over the 10 Caritas Processes, to which she surprisingly replied, "Wow I'm not sure I can do that, I'm not sure _I_ even know them."

One of the nurses handed her a copy of her book, after which she did give a pretty good review of the basic concepts, but I was still taken aback that she didn't know her own material well enough to cite them from memory (although she did admit that she planned to do a more thorough discussion of the theory in a more general-audience meeting later in the day).

I guess if I had to rate the meeting, I'd have to give it 2 stars out of 4.

Jean Watson: Caring Theory of Nursing... Caritas Processes...

Updated 3/14/2009

   Our hospital network is adopting Jean Watson's Caring Theory of Nursing.

Most nursing theories are based on Nursing as a humane and compassionate application of a scientific method. Jean Watson encourages us to "return to our core values", and recall the "original reason we all went into nursing", things we as nurses tend to forget when carrying out the "clipboard nurse" type of nursing, where we exhaustively collect data in the form of measurements and numbers. Watson asks all of us as nurses to be more "in tune to the moment" when interacting with our patients (she doesn't like the "customer" model of the modern hospital), and realize that our interactions can be more humane, significant, and caring.

Nursing, as the underling of the medical profession, often works to turn the human being into the human body, further breaking him/her down into just a "body", and eventually just a "machine."

Nursing work too often focuses on "doing" rather than "being", and has become too easy to "do something" to a machine, things we would never consider doing to a human being.

Watson describes ten "Caritas Processes". Originally "Carative Factors," she redefines these essential "core values":

Formation of humanistic-altruistic system of values, becomes: "Practice of loving-kindness and equanimity within context of caring consciousness

Instillation of faith-hope, becomes: "Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared- for";

Cultivation of sensitivity to one's self and to others, becomes: "Cultivation of one's own spiritual practices and transpersonal self, going beyond ego self";

Development of a helping-trusting, human caring relationship, becomes: "Developing and sustaining a helping-trusting, authentic caring relationship";

Promotion and acceptance of the expression of positive and negative feelings, becomes: "Being present to, and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for";

Systematic use of a creative problem-solving caring process, becomes: "creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices";

Promotion of transpersonal teaching-learning, becomes: "Engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other's frame of reference";

Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment, becomes: "Creating healing environment at all levels, (physical as well as non-physical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated";

Assistance with gratification of human needs, becomes: "assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials', which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care"; tending to both embodied spirit and evolving spiritual emergence; Allowance for existential-phenomenological-spiritual forces, becomes: "opening and attending to spiritual-mysterious, and existential dimensions of one's own life-death; soul care for self and the one-being-care-for.

 

Our new Clinical Director gave all of us Charge Nurses a copy of Watson's book, which I dutifully read and attempted to absorb over a weekend.

It's going to be a challenge for me. I've never been that "spiritual" or "metaphysical", instead relying on my scientific background thoroughly grounded in skepticism and empiricism. A lot of these carative factors / Caritas Processes are difficult for me to understand on anything more than an intellectual basis. In other words, I have been unable to bridge the gap between vocabulary and meaning.

Jean Watson is scheduled to come to our hospital tomorrow, and I'll be meeting with her along with other charge nurses throughout the hospital in a 90-minute presentation.

Links:

Jean Watson's information page from the University of Colorado Denver.

The Watson Caring Science Institute's page.

From RNJournal.com, a good overview.

Search Query Results from PubMed.

A Pragmatic View of Jean Watson's Caring Theory.   A Word document giving a general review of Watson's Theory and a case study of its implementation.  (Viewer).

 

 

Books I'm reading... Has the recession hit nursing? Arizona nursing layoffs...

I've been off for five days. I had made all these plans to go exploring with my Garmin Nuvi, but got a big huge attack of agoraphobia and stayed indoors almost the whole time (we did go groceries, and I drove to pick up another bag of IV fluids for LadyKitty, but other than that, I stayed in the whole time.

// Reading

I've moved on in my reading to two other library books:

  Yes I'm working on another Trek book, but this is the first one that deals with the crew of the very first crew of the enterprise, with Captain Jonathan Archer. It's been very well written.

 

After I finish the Star Trek book, I'll be reading another Dean Koontz novel.

 

// Has the recession hit nursing jobs?

 

Our hospital system has just introduced layoffs. I believe between the two hospitals, there were about 40 jobs lost. Most would be eligible to return to our hospital when hiring resumes. On our floor, we lost only one worker (that's one among a total of about 120 employees, and it was not a nurse).

 

I still feel that there are nursing jobs out there. What I think is happening is that, as the payor mix sours (more patients covered by less/no insurance) metropolitan hospitals will see the biggest change in their income. But I think if a disaster hits and I find myself laid off (which still seems very unlikely in my specific case) I would just hit the road and travel. There are plenty of places still hurting from the ongoing nursing shortage. The point will be to find work where the locals just don't want to go. I mean, I personally don't want a >20min commute, but if the only way to put food on the table is to travel 60 minutes each way, then that's what I'll have to do.

 

http://blog.azhealthenews.com/2009/01/15/banner-layoffs-deepen-gloomy-outlook-on-az-hospitals.aspx?ref=rss

 

http://www.nursezone.com/Nursing-News-Events/more-news.aspx?ID=18765

 

http://www.nursezone.com/Nursing-News-Events/more-news.aspx?ID=18803 (the link to the income/cost of living comparison is interesting).

 

http://allnurses.com/new-york-nurses/nursing-layoffs-300518.html

 

http://query.nytimes.com/gst/fullpage.html?res=9F00E7DF1430F93AA2575BC0A960958260&sec=&spon=&pagewanted=all

 

 

 

 

The Vice Presidential Debate ... A lot can change in four years ...

I thought it was a clear win for Biden, and so far the polls would agree.

I must admit, we watched the debate (24 hours later on Tivo) with the same anticipation some folks watch those "When Animals Attack" video's, wondering if I'd have to turn my head when the bloody part came. But Palin pretty much held her own. But I thought the raw construction of her answers was the same  evasiveness she showed in those tragic Couric interviews. I thought if either Biden or the moderator had the opportunity to really keep her on topic, and drill down for the gritty details, it would have become as incoherent and fragmented as her answers on the Couric interview.

She did get a good shot at Biden, when she said something like, "Oh Joe, I gotta wonder how much you guys are really thinking about the future when all you seem to do is point to the past." This after Biden continued to connect McCain to Bush. But it was a good jab that came off well on the TV.

On a side note, we got our early ballots today. My room mate took off with them, threatening to fill mine in with the Obama vote. I guess he never forgave my Bush vote 4 years ago, against his Gore vote.

Well really, I didn't know how it would turn out.

Those were such different days. My top concern four years ago was 9/11. All I could think of was that I didn't want another 9/11, and I didn't care if we had to hang the American flag -- from every capital building in the world. I joked about renaming Middle East countries as "New Texas" or "The Republic of Exxon." I really meant that back then.

Not so much now.

I still dread another 9/11, but don't automatically take the Hawkish view.

I worry more about the cost of my health care than the cost of a gallon of gas.

I have more to say about the definition of marriage and adoption rights, even though I plan neither.

I don't think it takes a Republican in office to keep my 401k afloat.

I worry about what I'll do when/if my doctor retires, moves or decides on a less demanding life.

I think about work from the perspective of 80 employees, not so much as one nurse and five patients.

I make cynical sneers at those "Be a Nurse" commercials on TV, even though I can't think of anything else I would rather be.

I fear more of us will die in horrible needless pain.

When I face angry patients, I first look at their hands (looking for weapons).

I used to look at their eyes.

So... a lot can change in four years.

Oh great, I work at the Hole...

This sign has been in front of the employee entrance of my hospital for months now. I used to think it was funny... charming even... but now that things have gotten a bit ugly at work, the sign infuriates me every time I pass beneath it.

I can't tell if the sign is missing the word "ass", "black", or "shit".

I've been spending the past couple of nights doing less "charge nurse" type bullshit duties, just to get back into the bedside caregiver routine. Even if I make the decision to remain as night shift charge, this whole experience has opened my eyes as to how much time I spend doing stoopid stuff. I'm not saying it shouldn't be done, but I spend a lot of time shuffling papers, keeping up files, keeping track of nurses' charting habits, and it seems all I really want to do is wipe asses participate in direct patient care. I was lucky, no big problems (except last night we had a guy drop his heart rate to 10) and most of the nurses on duty were as strong clinically as I am.

It was nice.

The drama over the resignation of my boss continues. I'm not saying I've been behaving badly, but there is the distinct odor of burned bridges in the air. Oh well, I just can't help myself when it comes to good 'ol email flame wars with the crazy fucks that can fire my ass.

Last night, there was a card going around the floor, with the night and day shift folks writing their goodbyes. They were all certainly heart-felt, but they all sort of said this:

Good Luck! God Bless! We will miss you! We have all learned so much from you! Take care of yourself! Godspeed!

This is what I wrote:

What the Hell is going on with the crazy crackwhores we work for? The stupid crap that has spewed from their worthless gaps has made me wonder if I'm too damn old to get into Law School... So go find us a nice place to work, and save room for me...

I mean honestly, I just can't help myself.

My boss is resigning, and I'm mad as hell...

After years of conflict with most of the physicians in my hospital, my boss is turning in her resignation. I really hate seeing her go, so much so that I wrote a letter to the CEO, the COO, the Vice President of Nursing, the Head of Human Resources, and the other charge nurses.

The letter sums up a lot of the frustrations I face as charge, and thought it made a good post. You can tell I'm angry because the more passionate I get, the longer my sentences get.

To set the mood, I'm replying to an email from my boss, Terri, who is asking me to reconsider my thoughts of giving up charge and returning to the floor as a staff nurse, a task for which I feel I am generally more suited anyway.

Let the drama begin...

Dear Terri,

 

These are terrible times, and I know, after a full day of emails and phone calls, that many of our staff are going through the throes of despair about what is going on with you. I think many of us are "reading between the lines" and have come to the conclusion that you are being forced to resign, if not directly, then at least in an indirect way by setting up a hopeless scenario. I think that is what is so upsetting to us, that someone who has so dependably and effectively served her staff so faithfully and fairly over the years is now subject to perceived unfairness and indeed cruelty. I know that you are making this decision based on your own needs, and on the best interests of our unit. I know this because you have always put the unit first, even at the expense of your pride and determination. We just don't want to sit on the sidelines and see one of our beloved champions get rail-roaded.

 

I know you have already made up your mind, but I hope you will consider taking back your resignation. Most of the day, I have spent reflecting on all of my own personal selfish reasons for keeping you as the Clinical Director. We have worked so well over the years, and I can honestly say without even a hint of hesitation or reservation that you are, by far, the most capable and gifted leader I have ever worked with, and I say that having worked every year of my life in a hospital setting, from the age of 17 until my present age of 47. I have worked with a lot of talented leaders. I have worked with a lot of incompetent leaders. You are the most gifted not only because of the mundane day-to-day challenges all managers face (the budget, staffing, recruiting and retention, blah blah blah) but you have an uncanny gift to allow your staff to not only enable their individual abilities, but indeed to amplify them. In the few years I have worked with you as charge, I have found new strengths previously unknown to me, and I have withstood personal and professional challenges that I simply would not have survived without your leadership. So, on a very personal and selfish level, your leaving represents a real blow.

 

We are all painfully aware of the ever-degrading relationship you have had with many of the physicians on our staff. I have seen firsthand how judgmental and unfair some of them (not all of them) have been, and I have witnessed you doing your best to not only give their concerns a voice among nurses, but also to give our version of the events to physicians who are angry. I have suffered verbal abuse and humiliation at the hands of physicians who, for whatever reason, do not fully appreciate the challenges we face on our Unit. They don't appreciate our level of turnover, with nurses at times handling four or five patients, along with admissions, discharges, and a system where physicians do not communicate with one another and thus leave gaps in the patients' care -- gaps which, when a nurse notifies a physician, subject too many nurses to anger for interrupted sleep, or too many phone calls, etc. The technical side of our profession increases ominously every year, and with it come challenges for nurses who must communicate with physicians. As our physicians yearn for a more "9 to 5" existence, this conflict is sure to become more violent and distasteful as the years go on.

 

I remember my first year as a new grad nurse, when we first started doing chemical cardioversion on the floor, rather than moving the patient to the Intensive Care Unit. My first cardioversion was attended by myself, my charge nurse, another nurse from the floor, the clinical educator for the unit, the charge nurse of ICU, two respiratory therapist, the attending physician, a resident, and the Cardiologist. In the span of a few short years, I now exercise the responsibility of literally stopping and restarting someone's heart, and do so with the assistance of another nurse and a respiratory therapist. Our skills over the years have grown, and I know with certainty that our skills have directly or indirectly saved the lives of many patients. However, on a daily basis, we are faced with the possibility of verbal abuse and belittlement from physicians who are not willing or able to communicate effectively with their own patients, who show no compassion for patients in horrific pain, or who show a heartless disdain for the families of the frail and elderly, who have the audacity to want to speak directly with their loved one's caregivers. We, on a regular basis, force air into lungs, shock hearts into beating again, and  rescue the most vague sparks of life, and yet we have been accused of falsifying patient weights, practicing medicine without a license, and not knowing how to do I&Os because we can't force an alert patient to measure his/her urine as instructed. These abuses are a constant nightmare that has sadly become a part of our profession. You have endlessly proven your resolve to be fair to all parties involved, and we all know you have now paid for this resolve in the harshest way.

 

When we spoke on the phone yesterday, you mentioned some survey that the physicians filled out, which may have played a role in your demise. As I think about this, I must admit that my eyes found themselves rolling to the back of my head with such sarcastic and unbelievable disdain, I fear I may have actually sprained my eyeballs. To think that some physician survey may be at hand, with a group of physicians with such a low Press Ganey rate of approval, makes me sick. The last I looked, the physicians had satisfaction rates as low as 10%, 5%, even 3% in some areas. These are shockingly low values, considering how difficult it is to get away from the "mean" score of 50%. I find it laughable that they can say anything negative about our satisfaction scores, which are well above the mean, and which we consistently strive, under your direction, to get as high as 90%, 95%, even 98% in some areas. I find it interesting that, while you resolve to beat the mean so handily, the physicians are beaten by these statistics so grossly. Some would consider it believable that they would "gun down" anyone that makes them look bad (and, Terri that would be you, we all know).

 

I also find it very telling that, as I contemplate leaving the charge nurse position (I know a hopeless cause when I see one), your first response was one of concern for the needs of night shift staff. Telling, but not so surprising. You are well known to put our needs above your own. If your leadership can not see this, then we all are surely heading straight to hell in the proverbial hand basket.

 

God save our patients.

 

God save our nurses.

 

God save us all.