bagwash

I must disagree. It's generally not OK to pray with patients. This is what Chaplains are for. While it may be OK to be silently present with a pt who is praying, if they request that, it can in some circumstances be an abuse of power to offer to pray with a patient. In my hospital, this kind of behaviour was occurring regularly, with nurses offering to pray with pts who had made no such request from them, and with several nurses informing pts that "bad spirits" were in their rooms or inside them and that they must pray to help get rid of them. This is medieval and very destructive. The nurses who were doing this sort of thing also were known to tell our (mentally ill) pts that all they needed was the Bible, and that if they were really good Christians they would not be so ill. Contrary to what these nurses believed, nurses are not employed to try to recruit souls but to provide care. I might strongly believe that socialism would improve everyone's lives, but it would be highly inappropriate for me to go about spouting Karl Marx. I guess it all comes down to staying on the fine line on the correct side of what the pt wants, rather than straying into the murky waters of what a strongly believing nurse may feel the pt needs.

Good to read your response, jerenemarie. I couldn't agree more. This reminds me that when I was told that my relative couldn't be suctioned because it was considered "traumatic". I thought: isn't drowning in your own respiratory secretions much more traumatic than a little therapeutic suctioning? Surely gasping for air and gurgling as you breathe is an undignified and extremely distressing experience (and a horrible way to die). So I must admit, I was quite shocked to realize that palliative care seems to mean the provision of comfort-assisting procedures only if they do not prolong life. I can't help feeling that the dollar-driven budget-slashed public system and it's focus on freeing up beds at all costs percolates it's way down to staff (without them even realising) and naturally ends up dictating the kind of care given. Incidentally, my relative is now completely recovered from both his pneumonia and his delirium, and is happily sitting up in bed reading all about the US election with great interest. Now he just has to face up to his metastatic cancer, which is what he came into hospital to get palliative treatment for in the first place. Hopefully we will get him home sooner or later and be able to enjoy a few more weeks or months with him.

Thanks for your comments and your kindness, Classicdame. I'm glad you can see that active treatment is not necessarily inappropriate in a pall. care ward. I could understand there being an objection to life-saving care in a situation where there is no quality of life, but not when the decision seems to be based solely on a person's age and prognosis. How can it be fair to not do what's possible to extend a life still worth living, especially when the treatment required is quite straightforward and likely to succeed? I think there is agism inherent in this kind of systemic decision-making about what constitutes a worthwhile life. I have friends whose "older" relatives (even as young as 59) have been deemed not worthy of life-saving care in emergency situations, for reasons such as that they live in a nursing home, have had a stroke previously etc, even though that person continues to lead a happy and interesting life with loved ones in regular attendance at the nursing home. Luckily his family fought for him and he survived his brush with the public health system. I find it strange that debate continues to rage about whether a sane person with no quality of life has the legal and moral right to legally end their own life (which I support), while at the same time, in hospitals and other facilities, people who want to live are denied care for various reasons, one of which is promoted as "rationing of the health dollar" based on these kind of discriminatory criteria. I've looked after (younger) pts having traumatic chemo, and even second bone marrow transplants (at incredible public expense) knowing it had little chance of long-term success but being willing to undergo it for just a few more mths of life.

One of my relatives was recently admitted to a palliative care ward for radiotherapy to relieve pain from spinal cancer. He has had prostate ca for 15 yrs, is 79 y.o and is otherwise in good health, is mentally bright, lucid and enjoys life very much. Neither he nor his family have ever felt he'd be "better off dead". Yet it felt like he fell victim to a system that had inculcated this viewpoint in its staff. I want to state categorically here that I'm not blaming any of the nurses or doctors, all of whom are good, kind people who work very hard for little reward. I see the situation outlined below as symptomatic of a system problem. Despite tests, the type of ca in his spine has not been pinpointed ("they ran out of tests" on the bone marrow specimen they painfully acquired from him--but they have excluded prostate and lung ca and multiple myeloma). This relative did not go into the pall. care ward to die. We did not have unrealistic expectations, but did hope for a few more weeks of life (some of us were hoping it might even be months). He is on heavy opiate meds (previously Endone and MS Contin--now Dilaudid). One day he aspirated after taking oral meds, having already been diagnosed with a chest infection. Next thing he had pneumonia. This is not treated other than with oral AB's. Sputum is not collected for culture and sensitivity as he hasn't the strength to cough any up. How about suctioning for some sputum?, I ask. Answer: We don't suction here--it's traumatic. How about some Oxygen, I ask. I get funny looks. A Dr asks my rel, who is totally out of it and gurgling like a drainpipe: "Do you think you'd be more comfortable if you had some O2?". How about some IV AB's?, I repeatedly suggest. More funny looks. Next thing he's having a series of rigors. Nobody does much, apart from moving him into what appears to be "the dying room" and letting us know "this is probably the beginning of the end". I ask for blankets and try rubbing him as this is what I've learned is the treatment for rigors. It seems to help, but gets me more quizzical glances. I start demanding O2 and they finally put it on at 2 litres/min. I ask about o2 sats but no one has done any, though he's been sick and wheezy/gurgling for 2 days, unbeknownst to me as I'd been working and wasn't aware he was going virtually untreated. No-one has taken his temp either, it seems. Eventually a Dr comes in who, it seems, has not been inducted into the "let nature take it's course" philosophy of the ward, luckily for us. He turns the 02 up to 15 litres/min; takes blood and starts IV AB's. He checks the O2 sats which are at 83%. For the next 2 days, my relative looks certain to die and we barely dare hope that he might pull through. I feel as though I've become most unpopular on the ward, but the staff remain kind and caring, just seemingly annoyed at my having demanded active lifesaving treatment for my rel. Amazingly he pulls through and all the staff seem shocked but are happy for us. Unfortunately he remains delerious but seems to be improving... Like I said, none of us expect miracles, but we did expect that treatable problems like pneumonia would be tackled in a serious way. Has anyone ever come across a situation like this?

Yep, sounds great, but unfortunately, I don't think it is ever going to happen, in our unit. The sad part is that I now think the only way I can survive in this unit is to be a lot more distant, more rigidly "professional" and to keep my guard up at all times, except with the pts I know are truly interested in recovery and able to behave respectfully.

Sounds like a great idea, Imustbecrazy. I'm not too familiar with Behavioural Intervention Programmes as such, but I get the general idea--consequences for unacceptable behaviour. Currently we have none, where I work, except for some limiting of privileges resulting from poor eating behaviours. Reprimands for brattiness from us ordinary RNs don't necessarily mean anything to them--except perhaps to provide yet another oppurtunity for them to be rude and display their defiance to all the other pts. They have no respect because we have nothing concrete to back us up. I think you're right, some of these young people have never had limits put on them, and they desperately need them. No wonder they have no self esteem, as growing up in such a structureless environment doesn't give anyone a sense of genuine worth. Sometimes I think they really need chores (not ones that involve energy expenditure of course!) to give them a sense of responsibility. It would be good to have a system where the pts earn trust and privileges. They won't get any rewards for curling up in a foetal position and cutting themselves, nor for beligerantly expressing every bit of anger they feel (whether justified or not) out in the real world. You have to wonder about the destructive long-term effects of hospitalisation, where these behaviours attract extra attention, and therefore reinforcement.

Thanks Emernurse, Meerkat and BSNtobe;I appreciate your feedback. The analogy with a junkie wanting his/her fix makes a lot of sense. Mind you, I worked in drug and alcohol (you guys call it chemical dependency) for over a decade but rarely encountered this kind of hostility! At least, not this pervasive, sniping, relentless hostility. I guess the bottom line is that they're in treatment because their parents have put them under duress to come in, not because they want to be there. It's just a bit tiresome when "kids" as old as 25 (!!) are still acting out their teenage rebellion fantasies (but still living at home when not in hosp., expecting mum and dad to fulfill their every need). Somehow I don't think hospital really helps them with their attitude problem. Being around their fellow ED pts just seems to result in a race to the bottom, i.e. a competition to be the sickest. In fact a senior psychologist I spoke with told me the evidence shows that treatment doesn't really work (at least, not any more effectively than no treatment). Bit demoralising to know that, but I think I remember reading it's pretty much the same with chemical dependancy. Everything depends on motivation. However, treatment does help keep them (ED patients) alive during the medically dangerous process of refeeding. As for coping with them, I do generally go for the option of ignoring the worst, most childish behaviour, but wonder if I wouldn't be better off telling them more often that rudeness isn't acceptable. It just never seems to work for me when I do try this! Not having kids of my own, I guess I haven't quite perfected the right tone of voice for such things. Thanks BSNtobe for the point about normal teenage behaviour. I don't remember feeling it was OK to be obnoxious and disrespectful when I was around that age, but I guess times have changed. I do find it wierd that kids now have such a sense of superiority, yet seem to remain immature and dependant for so much longer than back in the "old days". (I'm 47, so going back a bit of a way).

Sorry if this is an old topic. Couldn't seem to find the "search old forums" button. I work (as an RN) in an eating disorder ward. We get a lot of young (!4 to 25yo) pts who are mostly straight-out anorexics but also a substantial portion of mixed ED types as well (restricters who also vomit/binge/ substance abuse/use laxatives etc). Many pts also self-harm and have personality disorder traits... Of these sad, deeply disturbed girls, a small but very influential subset also seem to suffer from a sense of grandiose, almost narcissistic entitlement. This combined with their ambivalence about treatment and the irritability/mood swings caused by re-feeding creates a volatile combination. I should add here as a quick explanatory note: virtually all our pts are voluntary. I find these pts unbelievably rude at times--treating the staff like idiots employed solely for their amusement, giggling and running down the team and programme in whispering tones in a pathetically schoolgirl manner (more appropriate to ten year olds) and generally sneering and expressing their withering contempt without restraint. I guess it doesn't help that your average ED is a perfectionist +++ and they expect everyone else to attain the same high standard they consider essential to the simplest tasks. They are also control freaks e.g. tonight I was doing their BPs etc when the girl I was checking felt it necessary to inform me that I was on the wrong page (as I hadn't turned over from the previous pt's page yet). I assured her it was all under control, but felt like saying" Please don't feel you need to supervise me!". Anyway, the above behavious are pretty much standard fare, especially at the meal table where we eat with them and encourage normal eating behaviours and where we get all the expected "give me a break!" protests and looks that could kill at 2 paces. Guess that's what we get for being "the food police". More spectacularly, every so often we are treated to a full-blown tirade when we have truly enraged one of the pts in the "Little Princess" category e.g by expecting her to take a modicum of responsibility for behaviour. Yes. I am burned out! We get no support from management or debreifing. Many of these pts seem totally ungrateful and unaware that we are "busting a gut" (sorry--Aussie expression) to try to get them better and keep them safe from falling into the category of 20% mortality from their disorder. Sometimes I think they see us as mere servants--like waitresses (hence the "I'll have what I want and I'll have it now, or there'll be trouble!" attitude) or as low-grade maids/nannies, rather than as caring, overworked professionals deserving of respect. Any suggestions on how to cope with brattiness?

It's interesting to read this thread. I was always taught to dart the needle in (and to bunch up the muscle first) and I've always found patients tend to consider my IMIs less painful than other injections they've had. But when I started working in an Eating Disorders ward, my manager told me that good injection technique (on any kind of pt) meant you do not bunch up the muscle but pull it taut between thumb and forefinger of the other hand, almost flattening the muscle and then push the needle in. I watched her do this on one of our pts and it looked painful to me. It's hard giving IMIs to anorexices because they usually have a complex about anyone seeing their buttocks (scrawny as they are) so prefer to have IMIs in the deltoid--where there is practically no muscle (let alone any fat!) at all. We're talking about girls/women who weigh, at best, less than 50 kg, often less than 40kg and sometimes just on 30 kg. It's awful to give IMIs knowing they are going to be painful. I always go for a smaller needle but then feel anxious that perhaps it hasn't gone properly into what muscle they do have. One of the older RNs (thankfully no longer on the ED ward!) told me confidently that it was OK to give IMIs in the bicep. I queried this and pointed out where the bicep was, just in case she had meant the deltoid, but no, she meant the bicep. This woman used to be a nurse educator! She assured me "you can give an IMI in any muscle so long as you don't hit a nerve or blood vessel". I guess her sense of anatomy is pretty lousy as the radial nerve runs right over the biceps, apart from other reasons not to give it there, like it being too small. As for breaking needles off, we had a pt in the general psych area who'd become dependant on prescribed opiate injections (we call it pethedine, I think you guys in the US call it demerol) for "spasms" which her doctor was silly enough to believe required such an extreme remedy. She had self-injected large amounts for years and at one point, supposedly broken off a large part of a needle in her arm. As a result she'd developed a truly horrible infection, mostly caused by a common bug carried by cats and dogs and also present in the soil (can't remember which one). It had wreaked appalling damage to her lower arms (somehow spreading to the other one), to the point where she looked as if she'd been attacked by a wild animal. It smelt terrible as well. Perhaps the self-neglect associated with long term drug dependance had a lot to do with it, but she ended up being assessed as needing partial amputation. Her doctor never would face up to the fact that he'd helped her become a chronic drug addict, and he continued to prescribe the meds in large amounts while she was in our hospital. She had only to ring him complaining of the spasms for him to call the RN and insist she be given extra prn IMI opiates. These spasms were supposedly a psychosomatic, PTSD-associated result of self-defensive flailing of the arms following satanic abuse, believe it or not. Unfortunately her doctor did believe it, with pretty tragic results. Disclaimer: I'm not suggesting the woman lied about being abused, by the way --though I have grave doubts about the whole "satanic abuse epidemic" of some years back--only that the spasm story was way too out there to be taken literally).

I agree that there's a general lessening of responsibility (and also of basic courtesy) in society generally but where I work, in a small private psych hospital, it's the older RNs who are most guilty of unprofesssional behaviour. And when I say older, I mean anywhere from 60 to one RN who is over 80. No disrespect to anyone older out there, but these particular nurses have their own entrenched subculture where all sorts of things frowned on in the wider world of nursing are considered perfectly OK. E.g. predispensing of meds is very prevalent. They even do it right in front of the nurse manager (also older) while having a lovely chat about where they might go for their vacation etc. Another thing they do is disappear from their post regularly to wonder off to catch up with their colleagues for yet more extended chit chat. One of them feels quite comfortable about leaving all the keys (inc. all the drug keys and keys to offices) right on the front desk near the main entrance, where anyone could walk in and snatch them, while she is off somewhere ringing old pals on her cellphone. They won't wear the call/duress units so it's often impossible to find them. Because of all the time they waste (and because work is their main social environment) they hang around for hours after their shift, getting in the way of the next shift and driving everyone nuts. They all think of themselves as dedicated and caring and pride themselves on never taking a break, whereas to many of us it looks like they're on one long break all shift. I've never come across people who are so self-justified in their extremely slack and to put it bluntly, selfish behaviour. It's like they've retired already but are still showing up to be with their friends and collect a full salary.

Well, that's typical. One thing about managers in most places--they are bureaucrats and bureaucrats never want to hear about problems. At my work, we recently had a lecture on CPR at which they told us we needed to get out the defibrillator and start defibrillating a pt with suspected cardiac arrest ASAP. Only trouble is we've had NO training on using the defibrillator. But that's OK, they say, because the defib will "tell you what to do". If you've never even opened it or looked at it, I doubt that using it in an emergency situation is going to be that easy. The CPR lecturers had told us they'd had an hour's training on using defibs, which is significantly more than no training at all. I've brought this up with my manager and the Director of Nursing, but nothing has happened to remedy the situation in months. In the last year or two (getting back to the theory that managers avoid hearing about trouble) there's been a huge scandal here in Australia over a "surgeon" who practised in the state of Queensland in Bundaberg Hospital. He was living in the US when he applied or was headhunted for the job (where he'd been disqualified from several states for malpractice) and no-one ever checked his qualifications or references. It turned out he was not qualified or licensed as a surgeon and within a short time it became clear to his colleagues that he was dangerously incompetent and was in fact killing people. He has been nicknamed Dr Death and the Australian authorities are trying to have him extradited back out here from the US to try him for malpractice and I believe they are considering pressing murder charges, as he has been definitely linked with at least 18 deaths (but suspected of causing more like 80). When it became clear that he was, in effect, a butcher, the charge nurse of the Bundaberg ICU began making complaints to the higher-ups, who ignored her for months. Eventually they grew so tired of her "whining" that they told her it was all her problem and suggested she see a psychologist. They even insisted she attend training on "Dealing with Difficult People". It got to the point where she and the ICU staff were "hiding" patients from this doctor, trying to get them transferred to other hospitals before he could get his hands on them. This didn't go over well with management, who'd made this guy "employee of the month" and were paying him handsomely, so pleased were they with his high level of surgical intervention which was making the hospital lots of money. Eventually the charge nurse of the ICU went to a prominent politician and the story leaked out to the press and became a major scandal. The hospital then quickly slipped this doctor a first-class return ticket to the US and went about harrassing and threatening the charge nurse who'd blown the story. She has suffered greatly for being a "whisltblower" but is a hero to the relatives of the pts who were his victims. The hospital authorities have been unable to justify their actions and the embarassed state government are doing their best, it appears, to hose the whole thing down. A journalist researching the story shortly after it all hit the news did a 5 minute google search on the doctor and discovered his history of being banned from practising medicine in several states in the US. It was that easy. But for all the managers who protected him, patient safety was simply not a priority. (and aren't we all familiar with that attitude?). Even (or ahould I say of course?) his fellow doctors, who knew exactly what he was up to, didn't want to become labelled as troublemakers--it simply wasn't worth the trouble to unmask him even though to do so would have saved many patients' lives. It seems like it is always a nurse who is the one to come out and point the finger at these kind of dangerous practitioners, and afterwards, it's the nurse who pays the price, as he/she can expect to never work again.

I'm glad you asked! I would say 1, 3, 4 and 5. I'm a Registered Nurse in Australia. One thing that really bugs me is having to be a ward clerk--as well as a nurse, unpaid diagnostician, cleaner etc--doing things such as putting together admission packs, photocopying charts endlessly to replenish stationery stock (because management is too cheap to get a printer to supply them), booking tests for patients, ordering meds from pharmacy etc. Of course the photocopier is inevitably a long way from the ward and breaks down regularly and everything else that is needed for these supremely mind-numbing tasks is always arranged as illogically and shabbily as possible so that everything takes 5 times longer than it should. I really didn't go into nursing to do this kind of work--far from it. The other major pain is management who always seem to have totally unrealistic ideas about what can be achieved, which they maintain because they never get reality--tested by having contact with those strange creatures called patients. Their ideas are mostly totally inappropriate (and unworkable) and they (management) seem to exist in blissful ignorance of what their working staff actually think of them. It seems they do nothing other than get in the way of work actually getting done. It's best to tell them nothing and never argue, just work around them as best as can be managed. Lastly, I am sick of being expected to be an inexhaustable empathy squeeze-bag, who can suck up any amount of abuse from patients (I work in an eating-disorders ward) and still come up smiling, never needing any positive feedback or training/counselling to help one cope. Sometimes I think there must be an easier way to make a living...!

No need to hide behind the couch ChayaN Its good to be able to say what you think and hear other points of view and even change your mind-- or not, depending. Hope you enjoy your nursing studies

Here is the link to POWH http://www.sesahs.nsw.gov.au/POWH/ As for wages, I work 4 days a week and make about $60,000 per year. I would make maybe $70 - 75K per yr if full-time. You need to prove that you have at least 8 yrs experience to make the top rate. You get paid extra for working different shifts, weekends, public holidays etc. The flat rate (without the extras known as "penalty rates" ) is about $29.00 per hour. My wage above includes "penalties". If you don't work weekends the money is not great. Eg you get paid the flat rate plus 75% for working Sundays, or plus 50% for Saturdays. Hope this helps.

Hi MR, I have no idea how hard it is to jump through all the beurocratic hoops in order to be allowed to work here in Australia but I can tell you that they need nurses desperately!! I think the best trauma hospital in Sydney is Prince of Wales Hospital--a very large adults and paediatric public hospital near Coogee beach which is an attractive area about 15 minutes by car from downtown Sydney. I don't know about the nurse to patient ratio in ICU. There are no real trauma units in private hospitals here, as far as I know. They (private hospitals) mainly handle low level emergencies and elective operations. I expect you could get the hospital to sponsor you to help you get through all the paperwork. Generally Australian nurses don't have as high a skill level, as far as I know, as you guys in the US so hopefully your training would be acepted without having to do too much other than learning different names for the same standard drugs. I'll see if I can find a link to this hospital for you and post it next. Good Luck