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  1. Have Nurse

    It Never Occurred To Me.

    We'll call him John. John was 7 feet 2 inches tall. At 65 years of age, he had long brownish-gray hair, that he wore in a clumsy ponytail. He suffered from morbid obesity which made it difficult to ambulate as evidenced by his shortness of breath. A Viet Nam veteran, homeless, was found wandering the streets with a very high blood glucose level. He claimed he didn't know he had diabetes, which was possible. John hadn't seen a doctor in years. He was polite and cooperative, up independently and ambulating in the halls when we met. He had a distinct strong body odor. His day nurse informed me earlier that "He won't take a shower." I wondered why. Remembering that there is a reason for every kind of behavior, I decided to mull it around a bit before broaching the subject. He shared with me stories of his military service, how he got to be homeless and how he found himself in the hospital. "I was married once," he began. "It lasted 20 years....but then...she got sick and I couldn't keep up with the bills. We lost our house, she died....and suddenly it was all gone." He was sitting on his bed. I had pulled up a chair. It wouldn't be long before I had to do rounds again for vitals and meds, but I sensed a wounded spirit in him. A burden not just on his body, but in his heart as well. The elevator doors down the hall opened. The smell of hot food wafted down the halls. "John, " I asked gently, "Is there anyone I can call for you? A friend? Anyone?" He shook his head sadly. "Supper trays are arriving. Will you eat?" I was worried that his blood sugar would take a dive if he didn't. He nodded. I smiled at him and retrieved the tray. I still hadn't asked him about his refusal to take a shower. He allowed the staff to change his towels and linens. As John ate his supper, I reviewed his chart again and noticed how many times the previous shifts had offered him hygiene assistance but he would politely refuse. I also noticed that no one had charted on asking him why. Looking at the Allergies section of the chart, I noted no issues with soap or laundry products. Was he afraid of water? How long had it been since he had a decent shower or bath? Our homeless communities have access to showers and facilities so I was coming up empty on this one. Since he was a veteran, I knew he could handle it if I was direct with him, but it would need to be tempered with respect. Off I went down the hall. I walked into his bathroom, turned on the shower, set up supplies and towels and brought in a clean fresh oversized gown and fresh robe. He glanced up in surprise. I smiled at him and pulled up the chair again. His eyes still had that hint of sadness, so I reached for his hand and said: "John, part of my duties as your nurse is to not only keep you safe and help you get better, but I owe you the honor of being truthful and to offer possible solutions when at all possible. The staff, as well as myself, have noticed that you have not been able to get a shower in during your stay. You are beginning to give off a very strong odor and I am concerned that along with your medical condition, that you may be setting yourself up unknowingly for infection. The odor comes from bacteria, which loves to grow in dark, moist areas." I took a breath. "There are places on your skin that you need to get clean." I wasn't prepared for his response. "Well, " he began slowly, "I want to take a shower. But I didn't want to embarrass the young ladies taking care of me.....I'm so big and I can't reach where I need to, and I didn't want to make those young girls uncomfortable." This man was a true gentleman. "John," I asked, " I would not be uncomfortable with assisting you. Will you allow me?" He nodded with relief. I smiled. "After you, Sir." Yep, there's a reason for every kind of behavior. And sometimes, it's just plain courtesy.
  2. A friend approached me about caring for her elderly, increasingly disabled, parent. She told me about how her mom had become forgetful, slightly confused, and had a tendency to fall. Her worried eyes told me volumes about how overwhelmed she was and about her own confusion as to how to proceed. "So what do I do?" she asked with a sigh, "Mom refuses to move. She says she wants to die in her own home. I feel lost." As nurses, we are often faced with these types of questions. Sometimes they come from family, other times from friends and even neighbors. Whether it is a caregiving question or a treatment question or a need for a referral, our contacts look to us as professionals that can help. Most of us really do want to help. People often go into nursing because they long for an opportunity to make a hands-on difference to others-to really help their family, friends, and neighbors. In fact, the ANA's official definition of nursing includes many of these aspects, "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations." (What is Nursing?) When faced with a question like the one my friend posed to me, the temptation is strong to simply provide the answer, as we see it. After all, many of our experiences in most nursing settings provide at least limited exposure to potential solutions for caregiving quandaries. My own years of work as a parish nurse, hospice nurse, and even home health nurse immediately prompted a quick list to come to the tip of my tongue. The list would include my "Most Helpful Hints for People in Your Position." However, even longer experience of helping people reach their own solutions to problems led me to almost literally hold my tongue to avoid offering my own solutions. So how do we really help people that come to us with questions? Hold the answers As I pointed out above, serving up a tray with our version of the best way to proceed will most likely meet with rejection, dismissal, defensiveness and even anger. People know, instinctively, that we cannot possibly understand what they are really going through. We cannot know all things. Therefore, our particular solutions offer only a pale light to a murky puddle of problems. Listen first If we allow people to talk through their dilemma, they often circle back around to their own way forward. What we provide here is honest attention, encouragement, and maybe a prompting or two to help them focus. As nurses, we can be great listeners. We are trained to use our body language to show attention; we know how to reflect and rephrase comments; we have the background and scientific knowledge that makes us qualified as well as comforting. Be humble We can't really know everything. We are not walking in this person's shoes. Many years ago, I had a friend whose husband was diagnosed with pancreatic cancer. She knew that I worked hospice. He had the grim prognosis afforded to people with Stage 4. Her question was whether or not to pursue treatment. I realized immediately that she was not really asking me to offer my opinion. Under the tears, she showed a steely resolve to help him fight-he wanted to die in the fight. When she left, my heart followed her out the door, because I knew the pain that was ahead, but I also felt a lot of respect and love for two people who made a difficult decision, based on information they had been given. Ask questions Sometimes people feel jumbled, confused, weary. They have a hard time sorting through all the medical jargon to reach the message. Their difficulty lies in clarifying choices, simplifying and categorizing decisions to be made. After listening with humility, we can often ask a pointed question that will help make the matter less murky. For my friend who was dealing with her mother's care, I asked, "What are your mother's goals for this time in her life? What are your goals?" My hope was that by phrasing it this way, my friend would be able to see more clearly how to proceed. Present options If you are well-versed on community resources, you may be able to make appropriate referrals. If not, you likely know a case manager or someone else who can help offer direction. Many times, people feel trapped. They can't see a way forward. They suffer from hopelessness. Our job is to try to offer options-with options comes a sense of control, because if people feel that they have a choice, then the sense of being trapped is lessened. The choices may not be great but they are, nevertheless, a way forward. My friend ended up coming to a compromise with her mother: she installed a lifeline-type phone assistance, hired caregivers daily and worked out a weekend rotation with her siblings and family that provided a family member every weekend. It was a hodge-podge solution, not elegant, certainly not simple, but it worked for them. As nurses, most of us want to serve. Paradoxically, by being careful listeners, and actually refraining from fixing the problem, all the while admitting humbly that we can't see everything about the situation, we may truly be able to help.
  3. There's no denying the importance of good bedside manner: it helps nurses better educate patients and communicate effectively, which means more success after a patient has been discharged. Developing a bedside philosophy that's personalized - one that's focused on compassion and empathy, and one that's tailored to a patient - may be a good strategy for helping nurses achieve greater success in the form of healthier, happier patients. There's a wide range of research papers and studies emphasizing the importance of personalized nursing care. Overall, they indicate that taking a more personal approach at the bedside can equal improved outcomes in the form of better post-discharge care, higher in-patient happiness and fewer instances of medical errors. But the most important benefit of personal nursing care is that it helps improve the patient-nurse trust relationship. You Are What You Wear One of the simplest ways nurses are creating their own unique brand of personalized nursing care is through their uniforms. For example, nurses involved in pediatric care may wear kid-friendly patterned, character or holiday scrubs in order to help create a more personalized environment for kids. But it isn't just the nurse's hunch that leads us to believe this approach may trigger better outcomes; it's actually backed by science. Multiple studies show that multi-colored and themed caregiver attire can create a beneficial distraction for kids facing painful procedures and fear. For example, one study showed that wearing fun scrubs eased children's discomfort by over 96 percent, while another showed that the same tactic helped improve communication between staff and families by blurring the perception of authority between caregivers (who are often seen as authority figures) and patients. We know that this can be a valuable approach in pediatric medical environments, but what about when you're caring for the general population and the elderly? Well, the results are just as strong. Studies show that the geriatric population is equally as inspired by exciting and colorful scrubs. In fact, nurses who wear vibrant uniforms in hospice may be responsible for lifting patients' moods and sparking happiness. You're Only as Good as Your Ability to Listen Listening is one of the most important aspects of good bedside manner, and we're not talking about your stethoscope skills. According to the Journal of Patient Safety, upwards of 440,000 people die every year from medical errors. What do doctors and nurses cite as the most common reason for these errors? Miscommunication. In fact, the Joint Commission estimates that about 80 percent involve miscommunication. With all this taken into account, it's no surprise that active listening and proper communication are some of the most important ways to help caregivers provide effective, personalized care. In the book "Listening to Patients: A Phenomenological Approach to Nursing Research and Practice," the authors encourage the use of phenomenology - essentially, listening to a person's perception of their own human experience, and how they express it - in nursing. According to the authors, this technique may lead to altering the way that patients feel about their own conditions. But you don't have to get too philosophical to implement a listening-based care strategy into your bedside manner approach. There's a wide variety of communication techniques that can help you improve your listening skills to convey a more empathetic, compassionate disposition. Some literature to consider: A study published in ScienceDirect found that active listening and self-awareness were associated with empathy in medical settings, and that nursing students who practiced active listening improved patient-centered care. Another report from the Journal of the Academy of Medical Sciences of Bosnia and Herzegovina suggests that listening helps a caregiver better assess the situation before diagnosis, and that it can improve patient self-esteem. In "Effective Communication Skills in Nursing Practice," author Elaine Bramhall reports that external factors such as outside noise, lack of privacy and anxiety about feeling judged may inhibit proper communication that could lead to better care. A study in the Journal of Obstetric, Gynecologic and Neonatal Nursing showed that registered nurses who listened to high-risk antepartum patients helped improve the quality of the women's care, allowing nurses to provide better guidance about stress management. Knowing Your Patient is Vital to Good Care Getting personal with your patient by understanding his or her background, interests and concerns may be a good tool to helping nurses procure better care outcomes, according to studies. For example, studies indicate that patients who enjoy listening to music were able to better relax, control pain and trust caregivers when clinicians used methods of therapeutic music listening. Pediatric hospitals around the world follow a similar approach by creating kid-friendly hospital rooms complete with video games and toys. The same approach goes for a patient's ethnic background. Culture and language barriers are some of the most often-cited challenges for nurses looking for better ways to personalize care, but some techniques have helped to address this issue. Developing methods of "culturally competent care" - i.e. understanding certain cultural nuances of your patient base and working with a translator, if necessary - have been proven successful as methods of dealing with culture and language barriers in nursing care. Other hyper-tailored care methods have been developed by medical professionals to help improve care outcomes in the neonatal intensive care unit (NICU). Heidelise Als, PhD, the director of Neurobehavioral Infant and Child Studies at Boston Children's Hospital developed the Newborn Individualized Development Care and Assessment Program (NIDCAP), a customized program for premature babies, to help newborns reduce stress. Studies show that Als' method can help improve lung function, feeding and growth and brain function while shortening the time preterm infants spend in the NICU. The Bottom Line With all this fantastic research at our fingertips, we can deduce that higher levels of personalized patient care do, indeed, translate to better outcomes for patients. Revamping your bedside manner techniques to include more personalized methods - whether that means wearing colorful scrubs or using music therapy to calm patients - can help you advance your personal nursing techniques for the better.
  4. jeastridge

    Learning to Talk

    The doctor walked into the exam room where the patient sat on the edge of the exam table. In her late 50's, she was slender and held herself erect, tense as if preparing to slide off that paper-covered surface. The young doctor, maybe in her mid 20's self-consciously shuffled the papers she had in her hand. She stood a couple of feet from the patient and made eye contact. "I have the results of your tests, Mrs. T.," she said in a somber voice. "I've been anxious to hear them," was the reply. "You have a malignancy." The words were followed by a shriek of joy from the patient. "Oh, good, I was so afraid you were going to say that it was cancer." She held her hands to her mouth and seemed to hold back sobs of relief. The doctor began to stutter and her eyes widened, "No, yes, I mean...What I meant to say is that it is cancer, Mrs. T. I'm sorry I wasn't clear." The patient's relief gave way to a horrified look, followed by tears and mumbled words, "It can't be; it just can't be." Fortunately, the above scenario was part of a practice session in a class for medical students. The "doctor" was a young first year, learning that it matters what words we use when we talk with patients. I can remember as a hospice nurse, doing admissions and being careful about word choice. After explanations of our services, detailed checklists and signatures, the process usually culminated with a question and answer session just to make sure the patient and their family knew what to expect from us, their new hospice nurses. We tried to wait until the patient or the family asked about topics related to prognosis and then double checked to see what their medical provider had already communicated. Sometimes they did ask the tough questions: "So how long do I have?" or "What is going to happen as I die?" or "What do I do if I get to where I can't communicate?" It's important to consider how we answer questions that our patients pose to us and that we impart what truth we can with gentleness and compassion. In discussing this topic, my friend said, "Yes nurses need to talk....and so do doctors. Many times the doctor has told the patient a lot about their condition thinking they have covered everything. But the patient is confused by the 'Doctor Talk' and is embarrassed to ask for clarification. Then it is left up to the nurse to be the interpreter." How do we know what to say? Ask Questions Back First Clarify what they know, how much information they have and how they have interpreted what they know so far. It's Perfectly Fine to Say, "I Don't Know" Sometimes it is exactly the right thing to say. We are not at liberty, as nurses, to impart information about prognosis or testing unless the doctor has already had a chance to talk with them. Then we can clarify or help them understand what was said and what it means. It can be helpful to go one step further and say, "I will try to find out," but only when we really feel some measure of confidence that we will be able to find out. If we say we will and then get busy and don't get time to follow up, we will want to be sure and let the patient know what we were not able to follow up. Otherwise they may feel lied to or betrayed. Answer Only What They Ask We learn this with kids, often by answering a different question than they intended to ask. If the patient asks, "Will I have pain?" then it is helpful to answer that question and talk about strategies we will help them use to cope with the pain, without going into other symptom management problems that might arise later. Staying focused on the question at hand is hard to do, but an important learned skill. Know Yourself Work on your own issues when it comes to talking with patients. If people frequently mention that you talk a lot, then it might be time to pause and hold back from saying everything you think needs to be said. If you are quiet and maybe answer questions with one word responses, it may be time to expand your horizons in terms of patient conversations. Learning new ways to communicate with patients is not necessarily a skill that comes naturally; as with all of our professional nursing skills, we must hone our trade, observe others who are experts in the field, and learn as we go. Sometimes You Have to Initiate the Questions Part of being good at caring for our patients involves listening to what they don't ask as well as what they do. When a patient is silent, appears distressed or depressed, it may be time for the nurse to ask probing questions. I can remember a hospice patient who never, ever had any questions. He was dying from lung cancer and breathing made a lot of conversation difficult, but he was closed off from his family and from us as his hospice nurses. We tried to engage him but our usual approaches just didn't seem to break through. Finally, one of the PCTs sat down next to him and said, "I'm worried about you. You are awfully quiet. Will you share with me what's on your mind? I promise I will listen and try to help as best I can." The patient went on to share his anger about his condition and the fact that he did not want to be in hospice-he wasn't angry with us, he said, just the fact that he was sick. Their conversation ended with her squeezing his hand and acknowledging that she had really heard him, "I'm sorry that this happened to you. It really stinks." That encounter seemed to help break the ice in our caring for this man. He never did talk a lot or ask many questions, but her question to him seemed to clear the air. Whoever thought nurses need to learn to talk? As with all areas of nursing, learning to talk with patients and communicate well is a skill. It may come more naturally to some than to others, but there is no doubt that we can all improve, take hints from one another and offer pats on the back to our peers who do a good job talking.
  5. traumaRUs

    LGBTQ Patient Care?

    As our communities continue to diversify many of our patients now have the freedom to express who they are. This can impact the care we provide and in order to be sensitive to this, first we need to review some of the terminology. The acronym LGBTQA can be defined as: Lesbian (adj., noun) - A sexual orientation that describes a woman who is emotionally and sexually attracted to other women. Gay (adj.) - A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender. It can be used regardless of gender identity, but is more commonly used to describe men. Bisexual( (adj.) - A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender and people of other genders. Transgender (adj.) - Describes a person whose gender identity and assigned sex a birth do not correspond. Also used as an umbrella term to include gender identities outside of male and female. Sometimes abbreviated as trans. Questioning (adj.) - Describes an individual who is unsure about or is exploring their own sexual orientation and/or gender identity. Ally (noun) - A person who supports and stands up for the rights of LGBT people. There are many other acronyms used in this community and here is a resource for healthcare providers. AN had a recent opportunity to discuss this issue with Justin Milici, MSN, RN, CEN, CPEN,TCRN, CCRN, FAEN who is an Emergency Nurses Association member who provided input on ENA's Topic Brief: Care of the Gender Expansive and Transgender Patient in the Emergency Care Setting. Some transgender people do not use their birth names and are known as a different name. What suggestions do you have for nurses who may need to know their birth names and birth genders for insurance reasons, continuity of care or for some other legitimate reason? This is a common situation. If the patient has legally changed their name and has the supporting identification documentation, the new name can be used. If they have not legally changed their name, then their birth name must be used. In this situation, I first ask the patient how he/she would like to be addressed. I then explain to them that there will be situations that legally require their birth name, such as lab draws, radiology and other procedures and consents. I explain that this is required not only for legal purposes but for their safety. To "out" an LGBTQI patient could risk their safety not to mention their privacy. How should nurses ensure privacy of all patients? Nurses need to ensure privacy for all patients regardless of the situation. If a patient identifies as transgender, this needs to be clearly documented in the medical record so that the members of the healthcare team are aware and can best care for the patient safely. If a nurse inadvertently offends or uses the wrong pronoun, what would be the best way to handle this situation? Using the wrong pronoun is not uncommon, especially if this is a new situation for the nurse. Just simply saying, "I'm sorry" and then using the correct pronoun is often enough. Many hospitals are adopting different visiting policies aimed at LGBTQI patients and their families? How do you think a staff nurse could influence this policy? The nurse can influence this policy by simply being a patient advocate. Having a policy that fosters family presence while ensuring the privacy, dignity, well-being and safety of the patient is the best policy How can we deal with medical care disparities among the LGBTQ community members? LGBTQ patients, especially transgender, often avoid emergency department care due to: 1. Fear of discrimination due to their transgender status, and 2. Have had one or more negative experiences in the ED due to discrimination, which includes being asked intrusive questions, often having nothing to do with why they came to the ED in the first place. So, in conclusion here are some additional tips for healthcare providers when caring for ALL patients: Be sensitive to patients. Ensure privacy when discussing private matters. Don't ask for more information than that needed to care for the patient. Within your facilities' policies allow the significant other visit and provide support. Be respectful of same sex marriage and realize that this is may be a legal relationship in your state. How does your facility provide LGBTQ sensitive care? Do you think you have enough education to provide care in these situations? Other Resources: Communication Best Practices Improving the Healthcare of Lesbian, Gay, Bisexual, and Transgender People Opening the Door