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Nurse Beth MSN

Med Surg, Tele, ICU, Ortho

Hi! Nice to meet you! I love helping new nurses in all my various roles. I work in a hospital in Staff Development, and am a blogger and author.

Posts by Nurse Beth

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  1. What’s behind the reluctance to take the Covid-19 vaccine? Anti-vaccination sentiment is nothing new. There are many reasons, including fringe conspiracies. The surrealness of our lives in 2020, a lack of hard information, skepticism and social media all gave rise to waves of conspiracies. 

    One such conspiracy claims the vaccine contains microchips designed to alter our DNA and track our whereabouts. It even implicated Bill Gates in the narrative. But conspiracists and Covid-deniers are a small minority, as are ardent anti-vaxxers such as those who believe childhood vaccinations cause autism.

    But now there’s a new group, who are neither conspiracists nor anti-vaxxers. To some, it’s a paradox that this group includes healthcare workers.

    Anti-Covid-19 vaxxers

    “I’m not an anti-vaxxer, but…”

    The new group is anti-Covid-19 vaxxers. 

    Reasons for Reluctance

    It feels scary to inject an unknown substance into our bodies. Proponents are saying it’s safe now, but it’s understandable to worry about what’s as yet unknown.

    Fear of adverse effects 

    Some are not sure how the vaccine may affect their future fertility. Some say they do not want to be guinea pigs but might feel more comfortable in a few months after watching others and with real-world proof. Some believe the vaccine could cause future disease. It’s important for reporting agencies to be transparent about side effects.

    Misinformation

    One fear, that of being injected with the virus, is based on the understanding that most vaccines contain a version of the same germ or virus that causes the disease. But messenger RNA is not a germ or virus. mRNA teaches our cells to produce an immune response (antibodies).

    Lack of information

    Some who have been infected already believe it’s not needed because they have antibody protection. It’s not yet known how long antibody protection lasts. Can you be infected more than once? Cases have been recorded.

    Novelty and rapid research and development 

    Since vaccines typically take years, even decades, to develop, many are concerned at how fast the vaccines were rolled out and do not trust the accelerated process. Was safety compromised? Scientists say no. Researchers leveraged previous vaccine research and had newer technology as well as a lack of financial barriers.

    Cultural mistrust of healthcare authorities

    Mistrust in Latino and Black communities exists due to historic medical racism. Black males were lied to in the Tuskegee Syphilis Study for over 40 yrs, going back to 1932. 

    According to a Pew Research Report here's the breakdown by race of who would definitely or probably get vaccinated:

    • 83% English-speaking Asian Americans 
    • 63% of Hispanic 
    • 61% of White adults. 
    • 42% of Black Americans 

    The numbers speak volumes.

    Herd immunity: What is it? 

    Herd immunity is when a large percent of a population becomes immune to a disease, reducing the chance of person-to-person transmission by reducing the available hosts.

    The more contagious a disease is, the more people in the community need immunity. Measles is one of the most contagious diseases, and according to the Mayo Clinic, 94% of the population must be immune, which is the threshold for measles. Polio, smallpox and diphtheria have been contained by herd immunity.

    Originally the WHO said 60-70% but Dr. Anthony Fauci, head of the National Institute for Allergy and Infectious Diseases, has recently said herd immunity could take up to 85% vaccine coverage

    If entire communities of people refuse the vaccine then theoretically they are susceptible to the disease spreading quickly.  It could predict future hotspots of an outbreak.

    However, it has not been proven that the vaccine prevents transmission. It’s possible that immunized people can catch the virus, not become sick, but still pass it on to others.

    nurses-against-the-covid-vaccine.jpg.2ff30bc37bb95ebdcd84d56f221cfb9f.jpg

    Nurse Responsibility

    What is important is that we as clinicians stay informed on the latest vaccine data. Our words and actions carry weight with others. Be a source of credible information, and articulate your point of view.

    I am receiving my second dose in days, and it’s a personal risk/benefit decision. I am over 65, work in a hospital, and there’s a good chance I could get very, very sick if infected. 

    Be Safe

    Finally, be safe. I can’t recall the source, but somewhere in Europe, maybe France, a leader said “pretend you have the virus and act accordingly”  If everyone did that, we could reduce transmission by distancing and masking.

    Are you planning to get vaccinated and why or why not?

    Best wishes and stay healthy,

    Nurse Beth

    Author, "First-Year Nurse",  the ultimate insider's guide to helping new nurses succeed while avoiding first-year pitfalls.


    References

    Herd immunity and COVID-19 (coronavirus): What you need to know . nd. Mayoclinic.org Retrieved January 10 2021. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808

    Funk, Cary. Tyson, Alec.  2020. Intent to Get a COVID-19 Vaccine Rises to 60% as Confidence in Research and Development Process Increases. Pewresearch.org Retrieved January 10, 2021. https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/

    McNeil Jr., Donald. How Much Herd Immunity Is Enough?  2020. nytimes.org. Retrieved January 10, 2021. https://www.nytimes.com/2020/12/24/health/herd-immunity-covid-coronavirus.html

    The Tuskegee Timeline. Reviewed 2020.  CDC.gov Retrieved January 10 2021. https://www.CDC.gov/tuskegee/timeline.htm

    Doshi, Peter. Will Covid-19 vaccines save lives? Current trials aren’t designed to tell us.2020. Retrieved January 13, 2020. https://www.bmj.com/content/371/bmj.m4037

  2. 8 hours ago, Traumamama02 said:

    I guess I did this to myself, but I don’t see how or why when we are over ratio and worked to exhaustion  that this was a priority for discipline... how about teaching, guiding , giving tools for success?  Isn’t that what managers are suppose to do at lease some of the time?   I didn’t communicate assertively...you’re right ...  assertive communication gets us in even more trouble, yelled at in front of colleagues which adds to the low self esteem which leads to less respect which leads to less teamwork and adds room for clinical judgement errors because we begin to not trust ourselves and our intuition ... because we become dumb nurses in our own minds.    I can’t agree with my lack of assertive communication being my downfall.  Nothing you can do pleases this manager.  Nothing you say, no amount of kindness or distance from her keeps you safe from sabotage.   This kind of psychology damage is criminal when our mental health is already spread thin... 

    Thank you for your response.  It means so much to be acknowledged when it feels like the world is falling apart around you.  I appreciate you! 

    I don't think lack of assertive communication was your downfall (not sure I can say exactly what was, it was a situation that probably built up over time), it's a tool to help you when dealing with difficult people like your manager and to spare you some frustration.

    It honestly sounds like being away from this workplace is best for you. I hope you're able to put this behind you. Toxic people don't deserve your energy.

  3. Dear Beth,

    It’s me, ‘Sick to my Stomach’, I’m back looking for advice regarding the same manager who I felt was sabotaging me last year in February (I believe). I am now unemployed and I believe the manager played a part in my decision to resign.

    I’m also looking for advice on how or what I can do to help change the culture of bullying. I want to create a voice so loud that maybe somebody will listen, but I don’t know how.

    As you know, most of us are overwhelmed, overworked, morally distressed and are continuing to be where we are needed during this pandemic... except for in my case, until I was put in a position where I don’t trust the actions of the management team. I’ve been treated so poorly, I’ve talked to nurses who have been treated poorly and I feel like I need to do something to be the change in the culture of bullying and sabotage of nurses careers by fellow nurses.

    Colleagues confide in me, but only when I speak out about my own experiences. My most recent experience, the last straw that caused me to make the decision to resign, was just about two weeks ago when I arrived late to the Covid unit after working OT the night before. Regardless of working OT, late is late, and I am accountable for being late. I’m also accountable for making the decision to go straight to my assignments and not clock in. However, at the end of the shift we are also responsible to document our time of arrival in the missed punches book, a.k.a. the green book.

    As I entered the managers office and requested this green book I did so well announcing that I needed to do so because I was late and my manager proceeded to hand me the green book. As I’m writing my name I’m stating a loud that I’m not quite sure what time I got to work and then I was unsure exactly what to write and that I would be guessing. I get no response or direction from my manager so I say it again and this time her back is towards me, no response or guidance.

    At that point I’m tired I’m irritable I want to go home and I take accountability, this is my fault for being in this position at this time, however, in my opinion it’s obvious I’m requesting guidance. I then request that the time I swiped into the building be checked and used as my time of arrival because they do this anyway and have fired nurses for purposely falsifying their time entry. I am being open that I arrived late, open that I don’t know an exact time I arrived, requesting to be checked and corrected for discrepancies of the time I’m guessing and entering in the green book (we are required to correct entries the day of the missed punch) and use the badge swipe from the building as an accurate time of arrival.

    And still no participation from management for guidance. I close The green book and head home. The next afternoon I get a phone call from HR suspending me for time card fraud. I’m just beside myself that instead of calling me to come in and correct the time I knew I was writing as a guess, they called HR on me. I waited 24 hours after our meeting with my director and HR for them to call me with a decision of their findings and in that 24 hour time frame I decided even if they didn’t fire me I couldn’t work for them anymore because I don’t trust them now and I couldn’t give them a second opportunity to do something irreversible to my license.

    I sent my resignation letter and I’m just so overwhelmed with sadness because I honestly didn’t intend to commit fraud. I feel betrayed. I’ve never been accused of anything like this before and I don’t see how they feel I’m capable of doing this when I requested to be corrected. To be clear in the green book my entry stated 0707 but my building swipe into the hospital was 0709. Also to be clear 0707 is the cut off for rounding to the next pay bracket of 15 minutes so in their mind I was trying to steal 15 minutes of time from the company. What should I do if anything to create awareness if there’s even any awareness to be created from this experience. I just feel with everything I’ve gone through with the same manager, someone’s got to hear us who are targeted and address it.

    Dear Tired,

    You are tired, you are irritable and you don't feel respected. This recent incident, as you say, broke the camel's back.  You quit in a state of high emotion.

    Your estimation was off by only 2 minutes but represented 15 minutes of overtime to your employer and a reason/excuse for discipline, if they were looking for one. Perhaps it wasn't wise to choose 0707 as your clock-in time, knowing that it would be questioned and used against you.

    In any event,  what is in our control, even in toxic workplaces, is to communicate assertively. Your manager ignored you when you tried to talk to her, which is unprofessional. You could be more direct "I need some help completing this, please. I'm not sure of the exact time. What is best to put as my arrival time?"

    Frustration at work comes from many reasons- not feeling valued, not being heard. Learning assertive communication is the best tool against frustration. The only thing we can change for sure is ourselves, and sometimes that means choosing a healthier workplace where you are appreciated.

    Best wishes,

    Nurse Beth

     

  4. 1 hour ago, JBMmom said:

    Certainly we make recommendations to families all the time on aspects of care like code status, and we may recommend that families withdraw lifesaving measures in some cases, but that's based upon the clinical picture and prognosis for patients that we have had the chance to care for, not a split second decision based on arbitrary criteria like age, disability or other aspects.

    This a heartbreaking situation, I hope that the crisis passes without this becoming a frequently encountered situation. st. 

    Exactly

    33 minutes ago, caliotter3 said:

    I need to stop watching post apocalyptic TV shows and movies, especially the ones about pandemics.  They are losing their entertainment value when this is becoming the reality.

    It is surreal

  5. Overwhelmed hospitals in California are rapidly inching towards the abyss of rationing care. 

    • On Jan. 4, 2021, an LA Times headline readAmbulance crews told not to transport patients who have little chance of survival”. 
    • The same article included a directive from the L.A. County Emergency Medical Services Agency to withhold oxygen from patients with 02 sats of 90% or higher.
    • Two days later, the L.A. Times reported that Methodist Hospital in Arcadia, CA notified the California Department of Public Health that it would implement crisis care guidelines.
    • If a patient becomes extremely ill and very unlikely to survive their illness (even with life-saving treatment), then certain resources currently limited in availability, such as ICU care or a ventilator, may be allocated to another patient who is more likely to survive,” read the county hospital's message.

    Bodies are being stored in hastily ordered refrigerated trucks and morgues are turning away families. Patients are being cared for in hallways and tents.

    We’re all exhaustingly familiar with surge/contingency state by now, but the next tier, crisis care, takes us to the far and extreme end of the spectrum. Moving to a crisis standard of care is not optional, it is forced  (IOM 2009). It’s when all other options have been exhausted. 

    Crisis Standards of Care

    Crisis Standards of Care typically apply to the battlefield. It conjures up movie scenes of doctors and nurses stepping over the bodies of those likely to die to treat only those less likely to die. Once unthinkable in healthcare, the hows and whys of it are now being planned. 

    Warning

    We were warned to prepare for this scenario decades ago.

    “Therefore, the United States must continue to plan for a catastrophic public health event that will cause grave injury, disease, or death to potentially thousands or tens or hundreds of thousands in a city, region, or entire nation.” (IOM, 2009 pg 17). These words, written in 2009, sound almost prophetic when read today.

    Hospitals and states are required to formulate Crisis Standards of Care Guidelines to activate during a catastrophe. Once a facility, a county, or even an entire state declares they are operating under Crisis Standards of Care, rationing is in effect. It should be formally announced that the facility is operating under Crisis Standards of Care due to specific circumstances to protect nurses and for public transparency.

    According to the Institute of Medicine (IOM), Crisis Standards of Care are guidelines developed beforehand to help decision-makers allocate limited resources in a disaster. They provide a framework for decision-making when a hospital or system is so overwhelmed that it cannot provide the best care. 

    Decision-makers under extreme stress need guidelines when information and situations are rapidly changing or otherwise, a first-come, first-serve prevails. Without guidelines, front-line workers have to make life and death and supply decisions at point of need. Chaos ensues.

    Doctors could argue about which patients gets a ventilator, or dialysis, or ECMO. Nurses would have to decide who gets what medications and treatments first or not at all. Nursing assistants could compete to get blood pressure machines or oxygen tanks.

    Crisis Standards of Care aka Rationing 

    It will be called resource allocation by hospitals, and it means rationing. 

    Who Gets Care?

    Under Crisis Standards of Care, choices will be made to save the most lives, even if those choices are not in the best interests of individual patients.

    A triage officer is appointed and a team convened, ensuring no one person has to play God. The team could include doctors, nurses, spiritual care providers, and ethicists. Committee members will not include the patient’s nurse or doctor. 

    There are different ways to make such highly sensitive, ethical decisions. What are some criteria being considered?

    • Should age be a determinant? Preference given to a young person who has a full life ahead over a 70 yr old? But some 70 and even 80 yr olds still contribute a great deal, for example, Dr. Fauci, who is 80 yrs old, fit, and works 18 hr days.
    • What about people with disabilities? Some people with disabilities are afraid they won’t make the cut to the front of the line. Should someone with a higher baseline functional status be given preference over someone in a wheelchair, or someone with schizophrenia? 
    • Should likelihood of survival be the main decider? There are patients who have been on ventilators more than 30 days, more than 40 days. Currently if you are on a ventilator, the ventilator is yours until you improve or die. Under Crisis Standards of Care, it could be re-assigned after a period of time or if there’s no improvement.
    • Should those with chronic conditions and co-morbidities be given a lower priority? But won’t that discriminate against people of color, who have chronic conditions due to socioeconomic status and lack of access to healthcare?

    These are tough questions. Should patients during admission be asked if they would forgo being placed on a ventilator if there is a shortage?

    California guidelines state that a  person's age, race, sex, disability status, religion and ability to pay legally cannot be an explicit factor in making the decisions and proposes sequential organ failure assessment (SOFA) scoring.

     SOFA Scoring

    Some hospitals are already measuring SOFA scores.

    Scores measure oxygen levels, jaundice, kidney function and responsiveness. All things being equal, if 2 patients qualify for an ICU bed, it can go to the younger patient. Some patients who have been in ICU a very long time and are not improving based on condition scores may get removed or moved to a non-ICU bed.
     

    Is your hospital moving toward crisis mode? What are you seeing and what are your thoughts?

    Best wishes,

    Nurse Beth

    Author, "First-Year Nurse" the ultimate insider's guide to helping new nurses succeed while avoiding first-year pitfalls.


    References

    Berlinger, N., & WM, P. T. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: Managing uncertainty, safeguarding communities, guiding practice. (2020, March 16). https://www.thehastingscenter.org/ethicalframeworkcovid19/ Retrieved 2021,Jan. 4.

    Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers; Board on Health Sciences Policy; Institute of Medicine; Hanfling D, Hick JL, Stroud C, editors. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington (DC): National Academies Press (US); 2013 Sep 27. 3, Toolkit Part 1: Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK202382/ Accessed 2021 Jan 4.

    IOM. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012. http://www.nap.edu/catalog.php?record_id=13351. Accessed 2021 Jan 4.

    Hanfling, D., Hick, J. L., & Stroud, C. (2013). Toolkit Part 2: Public Health. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US).

    IOM (Institute of Medicine). Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: The National Academies Press; 2009. http://www.nap.edu/catalog.php?record_id=12749.

    Wigglesworth, A., Rong-Gong, L., Karlamangla, S, Money, L.(2021, Jan 4). Ambulance crews told not to transport patients who have little chance of survival. LA Times. Retrieved 2021, Jan 4

  6. Dear Nurse Beth,

    I just turned 59 and I am thinking of starting school to get my AS in Nursing. I think I can do it in about 50 credit hours, I already have an AA degree plus I was working on my BS in Medical Lab Technology. I stopped in going to school in 2016, I only have around 50 more credit hours for the BS. Will I be able to get a job, I was wanting to work in the Assisted Living Facilities, Long Term Care Facilities and with the Nursing Home Care Agencies.

    Dear Just Turned 59,

    Yes, an RN with an associate's degree (ADN) probably will be able to find work in a sub-acute setting. 

    The program itself takes 2 years, it's not self-paced. This is after you complete prerequisites, such as anatomy, Microbiology, and physiology. Check out nursing prerequisites at the colleges you are considering.

    If you were to start a nursing program 2 years from today, you'll be 63 when you graduate. Not impossible, but it's definitely on the older end of the spectrum to start nursing. 

    Best wishes with your decision,

    Nurse Beth

  7. 3 hours ago, Jedrnurse said:

    It's just a cynical gut feeling, but I can't help but wonder if some hospitals will try to make some of these emergency changes the new normal after the pandemic. (The ones that give them short-term economic benefit, that is...)

    No doubt. Either that, or I'm a cynic right along with you :). Some may try. But in the end, once the waivers are expired, it's back to ratios.

  8. 27 minutes ago, herring_RN said:

    From 1998 to 1982 I worked as an LVN in critical care after taking a critical care university course. (My fellow students were RNs planning to be Clinical Nurse Specialists. 

    Staffing was two RNs and me for six patients. Each RN was responsible for ongoing assessments and the entire nursing process for three patients. I took vital signs, wound care, administer routine medication, bring all IV equipment to the RN (Then potassium was added to IV fluid by nurses, bath, suction ET tubes as well trachs, trach care, ROM, positioning, assisting physicians insert Swan Ganz and other central lines, chest tubes, and other bedside procedures, and such. We were all busy as I helped with six patients, and they each had three critical care patients. I remember most of the time patients were well cared for. BUT it was NOT ideal. 

    Decades later I testified before the California Department of Health Services That there must NOT averaging of the number of patients and the total number of licensed nurses on the unit during any one shift or over any period of time. That ONLY licensed nurses providing direct patient care should be included in the ratios. I said, "If I have one patient needing 1:1 nursing care my colleague MUST NOT be assigned three patients as my hospital did. They claimed 1 plus 3 = 4, Four divided by 2 equals two therefore staffing in critical care the number of occupied beds is divided by two to determine staffing for the shift.

    But NOW LVNs could be very helpful.

    Thank you Nurse Beth!

    Bravo to you!!

  9. Cancer surgeries can still take place. Last week I recall a craniectomy. But ortho surgeries, hysterectomies, procedures such as colonoscopies...not. And I think the word "elective" is key.

    Our OR/PACU staff are directed to the floors to help as much as they're able, and GI lab is converted to additional ICU beds. 

    When ICU is at zero capacity, it's scary to think about a surgery going wrong and the pt needing an ICU bed. 

    The predictors say infections will peak at the end of January.

  10. 58 minutes ago, juan de la cruz said:

    It should be a last resort.  In many hospitals, over half of patient admissions in the acute and critical care units are from elective surgeries. Some of those surgeries are done because of the life threatening nature of the underlying medical conditions but some can actually be delayed.  Early in the pandemic, many hospitals actually cancelled a lot of elective admissions/surgeries in preparation for an influx of COVID-19 admissions but they never saw that surge...instead, they had empty beds for weeks which led to lost revenues for many that probably haven't been financially recouped.  I feel like many of the CEO's are not willing to go through losing revenue with that strategy again and are allowing the overcrowding to happen now.  Just my theory, I can be totally wrong in this.

    So true, we lived through that.

    But now CDPH has mandated " All hospitals and ambulatory surgery centers shall categorize all elective procedures by Tier using the Elective Surgery Acuity Scale (ESAS) from St. Louis University and suggested by the American College of Surgeons"

    I can tell you, hospitals here are not doing elective surgeries. It's real this time.

  11. Mine is a little different and may not be what you're describing...but at some point in my early years I realized that my value as a nurse is in thinking. Assessing. Analyzing.

    My value is not putting in foleys, or starting an IV, or other psycho-motor skills. Most of those could be delegated to trained personnel.

    It's seeing patterns and connecting the dots. Noticing an ever so slight increase in heart rate for no apparent reason. A drop in temperature. Looking for a source of infection, and realizing I'm seeing early signs of sepsis.

    Anticipating. Knowing the "Look-Good" and the "Look-Sick".

    I always said a lack of codes on a floor means the nurses are preventing codes- because there's most always warnings.

  12. 1 hour ago, scribblz said:

    I think we'll run out of nurses who know how to take care of vented patients first 😩 and if this ship doesn't turn around soon we probably will be rationing ventilators by Feb-March.

    That's a good point. I think finally it's sinking in how indispensable nurses are

  13. Update from Los Angeles:

    On Jan 4 2021 in the LA Times, the article headline read “Ambulance crews told not to transport patients who have little chance of survival” and included a directive from the L.A. County Emergency Medical Services Agency to withold oxygen from patients with an 02 sats of 90% or higher.