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  • Nov 4 '12

    I was thinking the other day, as I was reading some older threads, how often we hear concerns about doctors being rude or impatient with nurses. This certainly does happen. There are doctors out there who are just difficult to work with no matter how one approaches them. Thankfully, aside from a few exceptions, I have a good rapport with the majority of the doctors at my hospital. That isn't to say that they are all saints and have never been short or rude to nurses (myself included), but that isn't really what this post is about.

    Being a "doctor" doesn't give an individual license to be rude. Similarly, one could argue that neither does being a human being with the ability to communicate. Respect amongst colleagues is something we should strive for, and that is a two way street!
    What I rarely hear about is nurses being rude or impatient doctors, but it does happen. My thoughts on this matter have some basis in reality, which is why I am posting about this.

    There is a GP with privileges at my hospital who is very new. New to us, and also just brand-spanking new with the good fortune to take over a full practice after completing her residency. The GP she worked with retired, and she is now the family physician for his former practice. Where I work, GPs care for their own patients in hospital.
    This doctor is lovely, really, but it takes her a very long time to complete her rounds and often she runs out of time, must go to the clinic, and come back after clinic hours to see the rest of her patients. On her weekends on-call, she is literally on-site the entire day. She asks many questions, often consulting on-call specialists with advice on where to go with a patient's care, or calling the pharmacy to double-check information about medications. She asks many questions of the nurses, and often calls back to add or change orders.

    All of the above is because she is new, and when one truly thinks about it, it's perfectly reasonable. We always say to new nurses, if you are unsure, ask. That is exactly what she does, and wouldn't you rather she was thorough and not just guessing?

    I often see the nurses complaining about her. I've overheard the pharmacy techs and pharmacists complaining about her. She's always bugging us about something or she called again to change her orders! I wish she'd just figure it out the first time!! I've heard nurses snap at her when she's trying to ask them something about her patients. I imagine she may get snapped at by people on the other end of her telephone calls, too. Heck, I even overheard her own husband being inconsiderate to her on the phone - You've been there all day, what's taking you so long? Have I ever felt irritated with her? Of course I have!

    You know what? She doesn't deserve it. She hasn't even been practicing for a year on her own and she's doing the best she can for her patients. Could she alter her approach in some instances? Sure she could. Could she manage her time better? Likely. But learning those things takes time, just as it did for us nurses. She's like the physician equivalent of a new grad nurse and I feel badly for the way she is treated sometimes. It is a ton of responsibility, and a lot of knowledge that isn't always going to be right at her fingertips.

    My hospital uses a call group system for weekends, each group comprised of either one clinic or several smaller ones. One GP from each group is on-call for all the admitted patients in that group.

    Last weekend she was on-call for her group. I had four of her patients in the little 10-bed department where I was working, all of whom had some minor issues that should be addressed that day, but were not urgent. I knew she would show up at some point, but like most of the weekend doctors, she started her rounds up on the larger med/surg unit and would work her way down to us eventually. Therefore, I didn't call her, because there was no need to interrupt her.

    She finally came downstairs at 1600 that afternoon. I said "Oh, hello!" and she sighed and asked, "Were you waiting for me?"

    I explained as above, that we knew she would be along eventually so we didn't need to phone her. She looked so surprised and grateful, and it was that moment that started me thinking about this topic. I wonder how many times she was needlessly telephoned that day simply because she hadn't gotten to that patient yet, without anyone taking into consideration that she's slower than our seasoned GPs, and whether or not their concern could wait for her arrival.

    The following day, I intervened on her behalf when I strongly suspected her patient was about to either punch her, or shove her over when he was trying to leave against medical advice. She looked a little like a deer in the headlights, obviously trying to convince the patient to stay for his own benefit and having a very difficult time with his resolve to refuse care and leave. She wasn't reading the body language, and I happened to walk into the room to bring a dose of antibiotic and found her hovering far too close to an agitated man (face flushed, fists clenched) for my comfort.

    I tried my own, slightly different approach with the patient at first, but it was immediately clear that we would not get anywhere and he was going to leave no matter what. So I gently suggested that she go make her phone call and that I would take care of the patient until she returned. I removed his IV before he could just yank it out, got him to sign the release from responsibility form, and because I wasn't "forcing him to stay", he calmed down and agreed to at least pick up a prescription if she called it into his pharmacy.

    She thanked me afterward, and we discussed the situation and I felt a little like the teacher in that moment. If we forced him to stay, he would likely never come back even if he needed medical care. By letting him go, even though we didn't want to, I felt that at the very least, he would still get medical help if he needed it.

    I'm not discounting this doctor's intelligence or level of education, but in that type of situation, I have more experience, and she recognized and appreciated my help. That day we had a highschool work experience student observing, and she ended up seeing quite a bit of the "other" part of nursing, and the doctor said that she was lucky to have had me to follow for the day.

    Anyway, there aren't any great sweeping words of wisdom in this post. It's more about me expressing my thoughts. I'm going to work hard on not becoming irritated with her, going to speak on her behalf when others do. It may not be much, but if it helps even a little, then I'm happy to do it.

    Thoughts? Anyone else had a similar experience?

  • Nov 4 '12

    I have long despised the word "disability". While it's certainly an improvement over the frightful "handicapped", it still smacks of patronization, as in "Oh, we can't expect too much from Mary, she's disabled. Don't give her anything hard to do."Thus, I prefer the term "differently abled".

    Yes, it's awkward and doesn't roll off the tongue quite as smoothly, but I think it's a more apt description of nurses who have physical and/or mental health issues, and yet who bring many gifts and talents to this profession in spite---or because---of their condition.

    I wonder sometimes how a nurse who has never been ill in some way is supposed to relate to patients. Not that it's necessary to experience every human misery in order to take care of people, but let's face it: no one who has NOT been overweight or obese at some point in life can possibly understand what it's like to live inside a 300-pound body. Nor can a person who's never battled a serious mental illness comprehend the desperation that drives someone to attempt suicide. Patients need nurses who can at least imagine what they're going through, if not identify with them; they don't need perfect size-2 Mary Sunshine clones preaching at them from some lofty ivory tower.

    That's why it puzzles me that so many institutions, such as hospitals and high-end care facilities, are so leery of hiring nurses with a little sinus condition (so to speak). Whether they like it or not, nurses come in all sizes, ages, genders, and abilities. We are young and we are older; we have bad backs and bum knees; we get migraines and MRSA. Many of us fight anxiety and depression, in no small part due to the stresses of our work; in fact, I'd bet a month's pay that at least a third of us are on prescription medications for these (or similar) conditions.

    And yet, as judgmental as management can be toward nurses with "nonconformities" of one sort or another, that's small potatoes compared with the way nurses themselves view each other. It's a shame, but the truth is, most of us can spot another nurse's weaknesses with the accuracy of a sniper. It doesn't take much for the co-worker who's carrying an extra 50 pounds to be labeled as "lazy", the older nurse to be called "slow", or the one with labile emotions to be whispered about in the break room ("I think there's something wrong with that Mindy girl"). Nurses do eat our young, yes, but also our old and experienced, our empaths, our free spirits.

    What, then, can be done to assure a place at the table for every kind of nurse? Other than a full cultural shift in thinking, a good place to start would be for us as individuals to develop an appreciation of the gifts each of us brings to the profession. For example, I once knew a nurse who was a survivor of domestic violence, a woman so shy that most of our co-workers either ignored her or made fun of her behind her back ("she's so quiet that she could be dead for a week and we'd never know it"). It turned out that she knew how to calm violent patients better than anyone else---a craft undoubtedly learned from years of negotiating with her abuser---and after a couple of demonstrations of this ability, she became the one we all turned to whenever a situation began to escalate.

    Let us also try to view the "differently abled" at least as charitably as we do the perfect (or near-perfect). No one gets up in the morning saying "Let's see, how can I make life more difficult for my co-workers today?" The overweight nurse doesn't want to put anybody out or make them work harder; in fact, she's embarrassed when she can't move as fast as her thinner counterparts. But she's strong and she's kind, and she'll help you with chart checks and fingersticks when you're swamped at the end of your shift.

    Likewise for that odd little duck who runs hot and cold, isn't always sure of herself and tends to get easily distracted by competing priorities. She isn't being scatterbrained on purpose---trust me, the feeling of having all the TV channels on in your head at the same time isn't pleasant. Chances are though, when a psych patient who is desperately needy comes up to the floor and pushes his call button thirty times an hour, she'll probably be the one he opens up to, taking the pressure off other staff members and giving her something to do for which she is uniquely qualified. A win/win situation for all concerned.

    As Kermit the Frog used to say, it's not easy being green........nor is it easy being a nurse with medical or psychological challenges. Let us do our best to remember that everyone has something to offer, and that even the least among us has a talent or ability that can be used to benefit our patients, our employers, and one another.

    It's all good. Namaste.

  • Oct 31 '12

    "Good morning, good morning!" Michelle called cheerily as she approached the nurse's station. She was met with a couple grumbled good mornings and eye rolls. Most of the day shift staff weren't "morning people," and the night shift was definitely not in the mood by 7am. But Michelle always tried to have on a cheerful face when she came in. It just made the day better from the start. She checked the board and then approached Rosa for report. It was a busy day, but not too bad; besides, busy shifts went by faster. And she knew most of her patients from previous shifts, which was always a plus. She went room to room, writing her name on the board (sometimes with a smiley face). If the patient was awake, she did her best to spend some time chatting with them, despite the busy morning tasks looming. After that, it was time to ready meds and check blood sugars before breakfast. Jessica stopped her on her during her rounds.

    "Hey Ma-Belle," It was Michelle's nickname on the unit, born of the Beatle's song and a reference to Michelle's tendency to act like a mama hen to her patients. "Mr. Jenkins in 4C is refusing his heparin again. Would you mind giving it a shot?"

    "Ha! Nice one."


    "Give it a 'shot.' Heparin. Get it?" Jessica rolled her eyes and grinned at Michelle's corny joke. "No worries Jessica, I'll see what I can do." Michelle had a great bedside manner, and usually even the most difficult patients yielded to her warmth and compassion. After administering meds to her own patients, she stopped in Mr. Jenkin's room and, after taking the time to explain the importance of the drug and making suggestions for ways to minimize the bruising and discomfort he was experiencing, he finally agreed to the injection--if Michelle herself administrated it.

    "You've got the magic touch girl; I don't know how you do it." Jessica smiled from the doorway as Michelle gave the injection with perfect skill and ease.

    "Nah, it's different for everyone. There are definitely patients who give me a hard time."

    "That's a lie, but thanks." Jessica said with a grin. And the two women laughed as they snuck into the breakroom for a quick sip of coffee.

    Around 3pm, Michelle finally was ready to take her break. She was running a little bit late, because she stayed to help a PCA give a bedbath. It was a beautiful day, and Michelle smiled toward the sun as she walked down the block toward her favorite café. "Hi there, Michelle! The usual?" Called the man behind the counter.

    "Hey Louis. You got it. I'll be in the seat by the window." She sat down and started to read the novel she had brought with her, but it wasn't long before she found herself just staring out at the sunny day and watching people walking by. Louis brought her a chicken salad sandwich and iced coffee, and she thanked him warmly. After about 45 minutes, she started heading back; she always took a little less time on her breaks than everyone else. As she crossed the intersection back toward the hospital, a car ran the light and almost hit her--she had to jump back to the curb.

    "What the heck?! Watch it, scumbag!" She yelled after him as he raced away. Her heart was pounding. This was just the kind of person Michelle was--sensitive and empathetic. Nothing upset her more than to see someone being reckless or callous. It's what made her a great nurse. And despite the fact that the driver was totally in the wrong, Michelle felt bad for yelling at him.

    When she got back on the floor, things were quite busy. Luckily, most of her patients were either napping or off getting tests done. She had only one assessment to do, and the patient actually slept through the entire thing. Michelle chuckled and decided to let her sleep. She went back to her computer and began charting. At one point Jessica walked by, but the two women were each so busy, that by the time Michelle glanced up to say hello, her friend had already passed her. Michelle started to get up to ask her if she wanted to grab a cup of coffee in the break room, but the nurse manager caught Jessica's arm and asked to speak with her privately. Michelle started to sit back down, hoping Jessica wasn't in trouble.

    "Michelle? Michelle Muir?" A voice stopped her before she even finished sitting.

    "Yes? I'm Michelle." She turned and saw a tall man from Security at the nurse's station. Yikes, now she was hoping she wasn't the one in trouble!

    "I'm Sam. I have to transport a body to the morgue and was told to ask you for assistance."

    "Um. Ok, did one of our patients expire?" Michelle was wide-eyed. Had one of her patients died while she was on break? Had she done something wrong?

    "No, no!" Sam said reassuringly. "No one from this floor. But you see, I cannot go to the morgue without someone accompanying me. It's the rules." That was true. Hospital policy called for one member of the security team and at least one member of the hospital staff to accompany all bodies to the morgue. But it was strange to have someone pulled from another floor. Whoever had been accompanying Sam must have gotten called away before they made it to the sub-basement.

    "I just have to let my manager know. We're pretty busy."

    "It's already taken care of. I know you're busy, but I've been assured that you have time." Michelle glanced hesitantly toward the manager's office. She could hear Colleen talking inside; she sounded upset. Maybe better not to interrupt. Besides, it would only take a few minutes. Michelle logged out of her computer and walked with Sam to the security elevators, where the covered gurney waited.

    "I don't think I've ever met you before, Sam." She said, eager to make small talk to distract from the corpse.

    "No, I doubt you would have." Sam answered. "I'm from a special security department in the hospital. They only call us when they need us. That's why our uniforms are different." Michelle realized now that he was indeed wearing a much darker, blackish-blue uniform, compared to the light blue of the normal security staff. As they rode in the elevator, she marveled at how tall he was. He was super skinny too. The nurse in her began assessing, and she decided he was likely anemic, or at least at-risk. His skin was pale and fragile-looking, and it didn't look like it had good turgor. His eyes were a startling icy blue.

    "You look like you're sizing me up for a fight, Ms. Muir!" Sam's voice startled Michelle. She laughed.

    "Eh, I think I could take you, Mr..." She squinted at is name badge. "...Mr. Eyell." They both laughed as the elevator reached the sub-basement.

    They made their way to the morgue, both of them clearly familiar with where they were going. The morgue was not one of Michelle's favorite places, but she had been there a few times and understood it came with the territory. Sam punched in the security code and opened the heavy metal door. Michelle wheeled in the gurney and pulled off the sheets. The plastic body bag lay zipped underneath. She came back out into the main area of the morgue, where Sam was waiting.

    "There's no tag on the body bag." Michelle informed him. I'll have to fill one out. She grabbed a tag from the drawer and sat at the small desk. "Do you know the patient's name?"

    "I have it in her chart." Sam answered, his voice strange, and he handed her the binder.

    "Hmm. This chart is different from the ones I usually see. Where is the patient from?" Most of the floors had light green charts, but this one was jet black.

    "She came from ER, but you're right. These are special charts, used only by my department. We need to be able to differentiate them."

    "Wow, do you guys get different holidays too?" Michelle joked as she opened the chart.

    "Hey, wait a minute. What's up with this Sam? This isn't the patient's chart. It's just a list of names." Michelle flipped through the pages, where name after name was written in fine black ink, with dates listed to the right.

    "Yes. That's how our charts work. The patient's name should be on the last page, at the end." Michelle flipped past the pages and ran her finger down the list until she came to the last name on the list. Her blood ran cold.

    "What is this, Sam? Some kind of prank? What... what's going on here?!" Staring at her, in the same cold, black ink, Michelle saw her own name--Michelle Muir--written in perfect script. Today's date was next to it.

    "No mistake," Sam said, a little sadly. "My department is immensely methodical." Michelle jumped up, panic closing in on her. She was clearly trapped in the morgue with an insane man. The chair squeaked behind her as she stood.

    "Whoa. Like this place could get any spookier!" A new voice rang into the room, as Gary the mortician walked in with a doctor.

    "You get use to it, doc." Gary said. "Lots of weird noises around here, and things echo like crazy."

    "Oh my god! Thank god you're here!" Michelle cried. "Please, this man is pretending to be from Security! He lured me down here and I think he means me harm. I need a real security guard!" But neither of them even turned toward her, and Sam just shook his head sadly. Gary walked up to the body bag.

    "So what happened here, doc?" The doctor sighed and began to clean her glasses as she answered.

    "She works in Cardiac Stepdown. From what I heard, it was a hit and run. She was on her break when it happened. She expired on the scene. Based on the injuries, I think it happened so fast, she probably didn't even realize it."

    "Yikes." Gary said. "And one of ours. That's a real shame." The doctor nodded.

    "I've alerted the nurse manager on the Stepdown unit. She's informing the staff now, and a counselor is heading up. I think family is on the way. I should get back upstairs actually."

    "No!" Michelle screamed. "No! You can't go! What happened?! I need answers! I need help!" She grabbed the doctor as she turned to leave. Her hand went right through the doctor's coat. Michelle screamed and fell backward. The doctor gave a shudder. "Eesh. This place really is creepy. And close the fridge, Gary. I can feel the cold air!" Gary smirked and escorted the doctor to the elevator down the hall. Michelle, eyes wild, turned back toward the gurney, sitting alone in the cold dark room.

    "Ms. Muir..." Sam began. But Michelle shoved him away--she could touch him easily--and stumbled up to the body bag. She stared for only a moment before yanking the zipper down. She screamed and screamed. There it was, her own face, bruised and swollen, but definitely hers. "No! Please no! It's impossible!" She fell to her knees, sobbing.

    Sam was kind enough to allow her a few minutes. But finally, he walked in and zipped the bag up. She felt his hand drop on her shoulder.

    "Ms. Muir, I'm afraid the time has come for me to escort you from the building." Michelle stood wordlessly. She felt numb. As Sam led her out, she stopped at the desk.

    "The toe tag... I never finished it."

    "Don't worry Ms. Muir. It's someone else's job now. You've done all the nursing tasks you need to do today."

    They stepped back into the elevator and eventually reached the first floor. Sam kept his hand on Michelle's shoulder as they walked toward the exit.

    "Sam, where am I going?" Michelle asked.

    "I'm afraid they don't give me that information, Ms. Muir. I'm just the security escort."

  • Oct 17 '12

    I knew this was not going to be one of my better days when I turned into the driveway at my assisted-living facility this morning and saw not one, but TWO ambulances at the entrance along with a firetruck. Should've known the rainbow I'd spotted on the way in was the most peaceful thing I'd see all day......

    But wait, it gets worse. We had two residents complaining of chest pain, which is an automatic 911 call whether I'm in the building or not; thus the need for two medic units. This was AFTER another resident had fallen on noc shift and had to be sent out with a bump on the noggin. She was just coming back into the facility via medical transport when all hell broke loose with the chest pain sufferers; thus began the wild rumpus.

    The staff was getting the fall victim settled back in her room while the resident care manager and I started the paperwork on our two transports, when we heard a loud "BANG!" upstairs. This was swiftly followed by the sound of running feet and an "Oh (brown word)!!" from a staff member who'd forgotten to take her finger off the 'talk' button on her walkie. We looked at each other and repeated the phrase simultaneously; sure enough, another resident had bitten the dust. This time, it was a gentleman who'd sat on the edge of his chair and tipped the whole thing over---with him trapped underneath.

    Unfortunately, he was complaining of severe shoulder pain, he'd bitten his lip almost clean through, PLUS the fall had raised a baseball-sized lump on the side of his out he went too. The paramedics were beginning to roll their eyes at us, and one of them went so far as to quip, "Maybe you wanna stop pushing 'em downstairs?"

    About this time, Chest Pain #1 came back with no new findings, no cardiac issues, no new orders. Big shockeroo there---our local hospital, which is supposed to be so awesome with its Magnet status, rarely (if ever) investigates our residents' issues thoroughly, and all we can do is shake our heads and curse under our breath at the minimal "care" given to them. I mean, if someone brought me a pale, diaphoretic elderly gentleman with chest and jaw pain, I'd at least want tele and a series of cardiac enzymes, but I guess that's just me.

    Shortly thereafter, Chest Pain #2 arrived with a diagnosis of pleuritis. Who knew? She hadn't had a cough, shortness of breath, adventitious lung sounds---we didn't have a clue until she began to complain of classic cardiac symptoms. Unfortunately for all concerned, she hadn't been home more than half an hour before she fell over her cat and had to turn around and go right back to the ER, where she was diagnosed with two broken fingers.

    That was when the RCM tossed the handful of incident reports she was holding into the air and said "That is IT---I give up!!" By this time, though, it had all become so overwhelming that I did the only thing I can do in situations like this: I broke up laughing. I hee-hawed so hard that tears squirted out of my eyes and my asthma flared up, requiring a trip to the office for the inhaler I keep in my pen drawer.

    Swing shift was coming in at the same time, and I waved as I ran down the hall, inviting them to "Come, join in the IN-SA-NI-TEEEEEEE!" This prompted several of them to look at me rather strangely---they don't know my brand of humor like day shift does---and one girl looked almost as if she was ready to turn tail and run while she still had the chance. I wouldn't have blamed her if she had.

    It was after 1600 when things finally began to settle down. Everybody was back and tucked in, including the poor fellow with the goose-egg on his head, and five care plans were hastily being rewritten to reflect the events of the day. At long last, the RCM and I had a chance to sit down and decompress a little as we chewed over the bizarre series of occurrences.

    "What a DAY," groaned my co-worker, rubbing her temples as she spoke. "We can't even blame it on a full moon, or Friday the 13th. Sure hope we can get out of here before something else happens."

    "You and me both," I agreed. "I've had some crazy days working in long-term care, but this ranks with the craziest of 'em. I just hope tomorrow's better."

    A loud knock on our office door startled us as the receptionist barged into our cramped space, announcing with an indignant tone that one of the few residents who still drives---and shouldn't---had just backed into the RCM's car on his way out of the parking lot.

    As they say in the movies: another day!

  • Oct 14 '12

    As any nurse knows, a state survey or JCAHO inspection tends to bring out the worst in a facility. And as any nurse-manager knows, the survey team usually uncovers mistakes that we never even dreamed our departments were capable of---stupid, careless errors committed by staff who are too busy, too overwhelmed, or yes, too lazy to use the safe medication systems in place.

    Many years and many surveys/inspections after my very first as a manager---the one that got me fired for the first and only time in my career---I've come to be rather protective of my med room. When we bring on new med techs, the first thing I hand them is my dog-eared nursing drug reference and teach them to look up each and every medication they don't know, BEFORE they give it. But somehow, when State is around, we discover things like this little gem, written in the MAR by hand (and without a start date or initials to boot):

    "Lamidal 50 mg tab
    1 PO QD for urinary tract infection".

    First question: What the deuce is Lamidal? I'll be the first to admit that with hundreds of new drugs coming out every year, I'm always having to look things up (that's why my yearly drug book usually falls apart before the next edition arrives). But when I went to look up this particular med, I couldn't find it......anywhere.

    Second question: The resident's UTI had cleared up two months ago,and a follow-up UA had been negative. So why was she still taking a medicine for UTI? I realize that some patients must take prophylactic antibiotics for chronic UTIs, but this lady wasn't one of them.

    So I went to look at the original order, which was written in the typical doctor's handwriting. But it was clear as day that the order read Lamictal, 50 mg PO QD, which obviously is NOT for a bladder infection......and the mistake had continued from month to month. Needless to say, it made us look pretty foolish in front of the surveyors.

    Here are a few other issues that raise their ugly little heads during med transcription and administration that not only make even a good facility look really stupid, but endanger the patients our systems are designed to protect.

    Failing to actually read the order.

    You'd think it would be simple to transcribe an order like "Warfarin 2 mg tab, 1.5 tabs PO Q PM on Mon-Wed-Fri, alternate with 4 mg on all other days." But if you're not paying attention, you might see only the "2 mg tab" on M-W-F, and thus underdose your patient. It's a lot of fun to explain this to the anticoagulation clinic when they're on the phone demanding to know how the patient's INR could be 1.1 when he's supposedly getting 7.5 mg of warfarin 4 days a week with 10 mg on the other three....

    Giving an unfamiliar drug without knowing what it is, what it does, and what to watch for.

    How anyone can do this with a clear conscience is beyond me, if for no other reason than CYA. After all, it's your rear that's going to be barbecued when a patient is harmed and you have to testify in a court of law that you didn't know what side effects to monitor for because you never bothered to look up the med. And with the Internet available practically everywhere, this information is literally only a mouse-click away. There are NO excuses!

    Allowing distractions when pouring medications.

    At one facility where I worked some years ago, I had some trust issues with the staff, so I came in unexpectedly at dinnertime on a weekend 3-11 shift to see what was happening. Right out of the starting gate, I saw that two of the CNAs were in the med room, which was against the rules, and they were gossiping with the med tech while she was popping pills. Not once did I see the tech even glance at the MAR or the pill cards while she was doing it. And when I compared the med cards against the MAR, I found that she'd pulled the 2100s instead of the 1700s.

    Neglecting to document medications in all the right places.

    During our recent survey, we narrowly escaped a 'harm' tag for sloppy narcotics documentation on one particular resident who uses a lot of PRN pain meds. (Which should've triggered a pain assessment on my part, IF someone had notified me and/or IF I'd been auditing the MARs as often as I should.) The med would be signed out in the narcotics book and on the front of the MAR, but not on the back; or, it would be signed out in the narcotics book and documented on back of the MAR but not on the front; or, it would be signed out in the narcotics book and not accounted for on either the back OR the front of the MAR. Nine med techs almost had to go to OccMed and pee in a cup, while three managers holed up in the administrator's office for two solid days putting all the puzzle pieces together to prove that there was no narcotics diversion going on.

    Administering meds on auto-pilot.

    About a year ago, I was consulting in one of our sister facilities about their survey results, which made ours look like a walk in the park. At lunchtime, the corporate nurse and I watched in amazement as their med tech passed meds in the dining room, which included the administration of several insulin injections.....without benefit of the diabetic MARS in front of her as she dialed up each insulin pen. These happened to be perched on the table in the room we were occupying as we reviewed charts.

    When we asked the tech why she didn't take the book with her on insulin rounds, she responded casually, "I didn't want to bother you all. Besides, I know everybody's sliding scales anyway."

    'nuff said. These are all great ways to bomb a survey or inspection and put one's license at risk. Don't let them happen to you!

  • Sep 17 '12

    The first time I met Joe, I suddenly felt like I was in the presence of my own father who had passed away a few months prior. His stature, the way his blue eyes could tell a story... it was like God giving me this second chance to find some closure and acceptance to my own father's sudden death at 59. Nursing is more than a career and paycheck to me- it's life. I have always been intrigued with the medical field- as a young kid, I watched "Rescue 911". I wanted to be a hero- to give someone a second chance at life. I wanted someone to come up to me, wrap their arms around me and tell me that whatever heroic move I made, I somehow saved their life.

    As a nurse working in an Assisted Living in the Alzheimer/Dementia community, I don't do heroic medical techniques. I pass meds, I check blood sugars and blood pressures, and I patch up skin tears, tie shoes and occasionally pick someone up off the floor. I don't intubate or hook someone up to an IV. I do, however, try to bring my residents a little piece of the world. Their "world" is the halls, the bird aviary room, three meals, activities and snack time. During my downtime, Joe and I would take a walk outside. He would help me take out the trash, and he would tell me about his passtime of going to the casino. He had Alzheimer's- so at times, his stories would get a little mixed up but I would still nod my head and follow his story.

    One day, as we were walking outside, I found a dandelion ready for a "blow and wish." I picked it from the courtyard and explained to him that when I was a little girl, I would pick one of these out of my yard and blow it into the wind, making a wish and dreaming it would come true. I told him to try this... so he closed his eyes for just a moment, gave his "wish" a thought, and blew. He said, ,"I wished that I could play the machines and something would come out." (slot machines at the Casino) ... I knew I couldn't make that wish come true for that moment of clarity that he had for his wish, but I decided that I would try my best. As we headed back indoors after grabbing a bag of fresh popped popcorn, we walked to the lounge. I dug in my pockets for a few quarters, I handed the change to him, and told him to put it in the "machine" - he hit a button that I told him was the "lucky one" (diet Dr. Pepper- his favorite) and out popped a soda! His eyes teared up and he smiled and said, "I WON!!!" ..

    In the evening times, he would become a different person. Angry, anxious and lost in a world of his own. Sundowning, they say. When he was getting combative or argumentive with the caregivers or other residents, I'd take his hand and walk him to my office. Sometimes, he would be telling me stories that were quite off the wall, other times he took a snooze in the chair. He often carried his Bible around- although he was no longer able to see that great even with his reading glasses on. I would open it up to Psalms, read some scripture to him and he would close his eyes, take in what I was reading, and tell me to "go on..." My buddy Joe believed in God and drew me closer to my own faith. When he was losing his short term memory, no longer able to recognize his own daughter's face... he was still able to lay down his heart for God.

    Joe eventually had to move out and go on to another place- but last week I visited him. His eyes were a little more lost in the dark world of Alzheimer's... he was now using a cane, and a little more tired. I walked him to his room, sat next to him while he was in his comfy recliner. His old tattered Biblelayed next to him on his night stand. As he rocked back and forth in his recliner, I read some Psalms to him. He closed his eyes, said to "Go on" .. and soon I heard him snoring away. I gently woke him up, walked him over to his bed, and kissed him on his forehead. "Thank you sweetie pie"...he said. He closed his eyes and fell fast asleep.

    What made me get into nursing? Maybe it was because I knew that the older we get, the more we need a friend. The more life means, the conversations become more meaningful. All along I thought I needed to be the hero, but Joe knew better- he became the man that taught me about faith, love and patience- he was my hero in disguise. I see the world a little different now- and my buddy Joe sure enough opened my eyes- he brought the world to me.

  • Sep 13 '12

    C. Diff, MRSA and VRE are just a few of the diseases hospitals have taken specific measures to reduce cross contamination. These diseases have serious side effects and can further complicate an immune-compromised patient's chance of improvement. Evidence based practice has given staff protocols to reduce the chance of spreading these diseases and research has given antibiotics to assist in the treatment of someone already infected.

    But what about the disease that is more viral than any other? The disease that spreads like wildfire via the "Butterfly Effect" infecting the staff, patients and visitors? The disease that does not have an incubation period, is airborne and can be just as detrimental to patient outcomes as MRSA? What is this new superbug you ask? Attitude. There are two types known: Attitudinous vulgarious (A. vulgarious), or "bad attitude" and Attitudinous optimisticous (A. optimisticous) or "good attitude." In either version there are multiple variations, degrees of infection and can be hospital or community acquired.[i]

    Attitude spreads like wildfire no matter how many gloves, gowns or masks you have on. Have you ever walked into a patient's room, and no matter how bad they feel, when you greet them with a smile and a pleasant attitude, they can't help but smile also? BAM - you have just become part of the epidemic - someone caught your good attitude, if only for a moment.

    A. vulgarious appears to spread faster than A. optimisticous however both go 'viral' and affect the entire milieu of the floor. Who among us has not been yelled at during a typical day at work, more often than not, simply because someone else was having bad day? How did this affect you? Instant bad attitude? This attitude can spread quickly unless a conscious effort is taken to combat it. Many do not realize they have been infected until it's too late and have further spread the virus as well. We as nurses have more frequent contact with patients, visitors and other hospital staff and therefore have a higher chance of cross-contamination than, for example, a doctor. Although we can be infected by a doctor, we can then spread it to the transportation staff, who then infects the MRI staff, who then infects the nurse on another floor, so on and so forth, and now it has gone hospital wide.

    Unfortunately, there are no labs or diagnostics that can be done to see if someone has been infected or with which version they may have and once you are infected, you are a carrier for life. Only thru assessment and observation can staff determine which version may be present. Legally, nurses cannot be held liable for infecting someone with A. optimisticous however a legal opinion on the transmission of A. vulgarious is still pending.[ii]

    What can you do? The old adage lead by example comes to mind. Ellis holds five MEE standards, one of which is Attitude. This encompasses six values: be positive; promote forward thinking; recognize problems as opportunities for improvement; do not make excuses or blame others; leave personal business and problems at home and collaborate when problem solving.

    I try to be positive from the moment I step out of the car on my way to start my shift until I exit those double sliding glass doors to the parking garage when my shift is over (cue background music of angels singing and rays of sunlight shining down). Often on my way to the floor I pass people in the hall who have obviously not had the best of days but with the quick flash of a smile and a friendly 'Hi', they can't help but return the gesture.

    I like to think I promote forward thinking and recognize problems as opportunities for improvement. Some of the spread of A. vulgarious on the floor is attributed to staff-to-staff contact. If someone attempts to infect me I may briefly suffer some symptoms, however remind myself that I need to keep moving forward and that hanging on to that virus only distracts from the job at hand. I try to remind myself and others that it does no one any good to stay in a bad mood from an event that may have happened earlier. Inhale, exhale and move on. Problems are always opportunities for improvement and discussing them with other staff members can open your eyes to a solution you may not have come to on your own. I find my co-workers great resources professionally and personally and value their input and opinions.

    I try not to make excuses or blame others, which can be a difficult task if infected with A. vulgarious. I try not to spread my bad day to others however no one is perfect and this can be more challenging than it sounds. I make a conscious effort to go into each room as if it were my first for that day, leaving behind what may have happened in the staff lounge, at the nurses' station or in the previous room. It is important to remember though that if someone has a Stage 4 infection of A. vulgarious they may not feel any relief no matter what interventions you employ. At this point it is important not to blame them, but to remember that everyone is going through their own issues; treat them with respect, an open ear and be a sounding board. Sometimes the only intervention required is the openness of another to listen to the infected. Often I collaborate with others when it is the patient that is infected to obtain their thoughts and points of view on how to best treat the patient. Other staff may know the patient better than I and already have some coping strategies they have employed. They may know that "Larry," who is unable to control his bladder and bowels, gets angry when he is incontinent and this can upset him for the entire shift. Therefore, a concerted effort is made to get Larry to the commode frequently. When this effort is successful he is happy the entire shift and much more pleasant to be around.

    Lastly, I try to leave personal business and problems at home - Lord knows there are enough at work to go around!

    [i] Centers for Medicare and Medicaid will no longer reimburse for hospital-acquired A. vulgarious.

    [ii] Scrooge v. Polyanna, 24B N.Y. Niner.

  • Sep 11 '12

    "Please, help my son! He is dying!" - a middle aged man screamed as he entered the emergency room.

    I looked up and saw one little boy age of nine in his arm with so much blood on his body. The blood is whooshing from the boy's body ... at this point, I'm not sure where it's coming from. Oh, God!

    I guided the father to resuscitation room or red zone. Alerted the doctor and got help from ward's staff. Gave patient oxygen and set up all the cardiac monitor and blood pressure cuff. While doing everything I realize that there was a huge, deep, and open trauma on his back at the scapula region. I can see through it.

    I instructed the hospital assistant to help me press the wound to stop the bleeding. As I helped the doctor in assisting him in intubation. At this point, I thought only a miracle can stop the bleeding. A few minutes felt like hours - "Where is the other staff?"

    "Please I need help! I need someone to set the IV cannula! This boy is losing so much blood!" After successful intubation, I gave chest compression while the father was helping in giving manual ventilation through bag ventilation mask - with a lot of tears in his eyes while the doctor is trying to get vein for IV. An RN arrived, she stepped back after seeing so much blood. "Sorry, I can't stand to see all the blood." I was shocked when the words came out from her mouth.

    "Oh, My God! Help me please. Get me someone else!"

    Being new RN grad and working in this small center makes me have to work on myself really hard with a little experience. On that day, I'm working afternoon shift with two hospital assistant and one medical officer and it's on a holiday! I'm putting all my knowledge and what I learn through the three years of nursing school and clinical.

    The center that hired me is small but have a BIG sign of EMERGENCY 24 HOURS outside of the building with a bright light and you can saw it from 1000 meter far but the facilities and staffing is poor. That condition put my career and other patient's life in danger.

    I just graduated 8 month ago from nursing school and have only 6 months of working experience and they put me as in charge RN all by my own with one doctor and a hospital assistant who doesn't even know how to take blood pressure.

    This boy could have been saved if a proper management, fluid resuscitation, and controlling the bleeding by binding and compressing the wound. When the doctor gave instructions to stop the resuscitation I couldn't hold my tears.

    Now, after four years in nursing I never forget what happened on that day. I still think about the RN who chose not enter the resuscitation room cause of the bloody body. I remember blaming the hospital management for their poor management and staffing. I even blamed myself for the lack of knowledge and experience I had. I learned from his father that his son was hit by a car while cycling in their resident area and that day was the boy's birthday.

    Being a nurse and by choosing this career, we must be aware that we will be responsible for saving people. We need to accept that seeing blood is routine. Please don't sacrifice another person's life by choosing this career if you do not have the stomach for it.

    For those newly graduated RN, you will be facing 1001 kind of cases and incident through your career. Some will make you feel inadequate. Never give up. It's just another way for you to learn - to become a great nurse. Go on and never stop learning!

    I quit from the hospital and looking for new job at well organized center. Now, I'm in the middle of taking my Advance Emergency Medical Trauma Care certification and I never forget the incident that happen on that day. From that day, I promised myself to become the best nurse that I can be. A nurse who can handle any emergency conditions and save lives.

  • Sep 11 '12

    LOL! I like this one.

    How many hours of sleep do you get? Do you have certain rules that household members must follow?

    Any time management tips for sleep deprived nurses?

    Click Like if you enjoyed it.

    Please share this with friends and post your comments below!

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  • Sep 9 '12

    So there it was the start of my shift.....

    Insane patient load......

    The lab guy was on the floor looking frazzled.....

    He said hey, the guy in room so and so has a picc right? I say yup...

    He said hey can you draw from the picc for these two tests...I will leave the tubes for you......

    even though it was gonnna be way hard on my time I told him no worries....


    A stat order comes in for blood cultures on one of my pts.....

    Day is going crappy and this is just another monkey wrench.....

    I grab the kits and put them on pts bedside table and run to answer a light.....

    When I get back, there is the lab guy telling me...hey man, I got this....

    We smiled at eachother and I said thanks man......

    Awesome team work

  • Sep 7 '12

    You don't need to really care (in a touchy-feely way) to be competent. Give me a cynical, world weary battle axe who knows her stuff over a Florence nightingale who's an airhead any day.

  • Sep 7 '12

    I started to write a short essay about what I thought needed to happen for the role of nursing to advance. Science, medicine, specialization, higher entry requirements, residencies,... Then I got to thinking (always a dangerous thing this late at night), I doubt that nursing will advance much further as time rolls on.
    Hospital nursing is going to become a victim of technology and budgets. UAPs are taking over many of the functions of nurses. Almost anyone can be taught to draw blood, hang an IV and punch in a few numbers(or the iv will be preprogrammed for the patient), take vitals and hand the TV remote to the patient. Med techs can pass medications. CNAs can fetch water or a blanket, clean a patient and distribute meals. Robots are becoming evermore common roaming the floors. In the (closer than you think) future, virtually all aspects of a patient will be monitored, with supreme accuracy, from a central site. I can easily see a time when any MedSurg floor can be staffed with one RN whose role will be to oversee the other personnel and equipment and take care of emergencies.
    Eventually, charting will be akin to the automatic log created by an automobiles' computer. Just punch in the patients ID# and everything that that patient has experienced from the moment they were admitted will be printed out. Doctors will not need a nurse to call them about a change of condition, the computer monitoring the patient will digest all the info being gathered and using incredibly complex algorithms will be able to text immediately the new condition of the patient.
    "Now, wait a minute", you may say. "Nurses have a scope of practice that only they can perform." Scope of practice can be changed legislatively. And when the hospitals start to realize the saving$, do you really think nurses can battle them in the legislature? Especially when it will be presented as a means to cut healthcare costs?
    Hospital nursing is going to be vastly reduced. The way this profession will survive will be in ICU, ER, home health, hospice, satellite clinics, industry, nursing homes, and advanced practice, (that as time goes by will be less and less like traditional nursing).
    I, undoubtedly, have some of these things wrong, but the general belief that technology and budgets will force a reorganization of the profession will still hold true.
    As mentioned, nursing is considered to be part of the room decor, and you know how easy it is to replace a flower pot.
    Maybe I should have stuck with the first essay, it might have been shorter and stayed with the original spirit of the thread.

  • Sep 6 '12

    So where I work....its crazy, insane, frenetic LOL. After 14.5 hours I head to my car and see a note on my window. The CNA that I worked with had left it and it read....."You are a great RN".

    Now I disagree with that. I am a baby RN, still learning but getting stronger everyday. Truth is he is a great CNA. I felt like a jerk all day because I just was not able to help him as much as I like to.

    The fact that he took the time and effort to leave the note was really meaningful to me. Without him, the day would have been impossible. He is head and shoulders beyond our average CNA. He rocks!!!

    Again, thank you to all the wonderful, fantastic CNA's out there. You are the backbone of the floor.

  • Sep 5 '12

    It's All About Women

    A sweet lesson on patience.

    A NYC Taxi driver wrote:

    I arrived at the address and honked the horn. After waiting a few minutes I honked again. Since this was going to be my last ride of my shift I thought about just driving away, but instead I put the car in park and walked up to the door and knocked.. 'Just a minute', answered a frail, elderly voice. I could hear something being dragged across the floor.

    After a long pause, the door opened. A small woman in her 90's stood before me. She was wearing a print dress and a pillbox hat with a veil pinned on it, like somebody out of a 1940's movie.

    By her side was a small nylon suitcase. The apartment looked as if no one had lived in it for years. All the furniture was covered with sheets.

    There were no clocks on the walls, no knickknacks or utensils on the counters. In the corner was a cardboard
    box filled with photos and glassware.

    'Would you carry my bag out to the car?' she said. I took the suitcase to the cab, then returned to assist the woman.

    She took my arm and we walked slowly toward the curb.

    She kept thanking me for my kindness. 'It's nothing', I told her.. 'I just try to treat my passengers the way I would want my mother to be treated.'

    'Oh, you're such a good boy, she said. When we got in the cab, she gave me an address and then asked, 'Could you drive
    through downtown?'

    'It's not the shortest way,' I answered quickly..

    'Oh, I don't mind,' she said. 'I'm in no hurry. I'm on my way to a hospice.

    I looked in the rear-view mirror. Her eyes were glistening. 'I don't have any family left,' she continued in a soft voice..'The doctor says I don't have very long.' I quietly reached over and shut off the meter.

    'What route would you like me to take?' I asked.

    For the next two hours, we drove through the city. She showed me the building where she had once worked as an elevator operator.

    We drove through the neighborhood where she and her husband had lived when they were newlyweds She had me pull up in front of a furniture warehouse that had once been a ballroom where she had gone dancing as a girl.

    Sometimes she'd ask me to slow in front of a particular building or corner and would sit staring into the darkness, saying nothing.

    As the first hint of sun was creasing the horizon, she suddenly said, 'I'm tired.Let's go now'.
    We drove in silence to the address she had given me. It was a low building, like a small convalescent home, with a driveway that passed under a portico.

    Two orderlies came out to the cab as soon as we pulled up. They were solicitous and intent, watching her every move.
    They must have been expecting her.

    I opened the trunk and took the small suitcase to the door. The woman was already seated in a wheelchair.

    'How much do I owe you?' She asked, reaching into her purse.

    'Nothing,' I said

    'You have to make a living,' she answered.

    'There are other passengers,' I responded.

    Almost without thinking, I bent and gave her a hug.She held onto me tightly.

    'You gave an old woman a little moment of joy,' she said. 'Thank you.'

    I squeezed her hand, and then walked into the dim morning light.. Behind me, a door shut.It was the sound of the closing of a life..

    I didn't pick up any more passengers that shift. I drove aimlessly lost in thought. For the rest of that day,I could hardly talk.What if that woman had gotten an angry driver,or one who was impatient to end his shift? What if I had refused to take the run, or had honked once, then driven away?

    On a quick review, I don't think that I have done anything more important in my life.

    We're conditioned to think that our lives revolve around great moments.

    But great moments often catch us unaware-beautifully wrapped in what others may consider a small one.

  • Sep 2 '12

    Although I do not regret this career (yet), I'll readily admit that my personality is not compatible with nursing.

    I am an introvert who does not particularly like meeting new people, even though I put on the acting game for the sake of my patients. In addition, I am not the type who seeks validation or deeply desires to 'be needed' by others. I also do not have a yearning to help people. In a nutshell, I am a self-centered person with no sense of altruism.