AACN News—September 2001—Opinions

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Vol. 18, No. 9, SEPTEMBER 2001


President's Note: A Journey of Rediscovery: Caution! Low Road to Self-Doubt Ahead

By Michael L. Williams, RN, MSN, CCRN
President, AACN

The nurse had taken care of both elderly men a couple of days earlier in the same thoracic ICU. For one, it was his third day after open-heart surgery. For the other, it was day 25. That’s right, the typical Day 25 clinical picture in all of its complexity. However,

the first patient was the sicker one. He had undergone surgery with an undiagnosed preoperative pneumonia. Now he had a fever, an elevated white cell count, lots
of foul-smelling sputum and an ugly chest x-ray.

The 12-hour shift was busy. Bathe and shave these patients. Get them out of bed. Help them back to bed. Turn them. Hourly mouth care, which didn’t help the odor, but hopefully felt good for the patient. Assessments, vital signs and medications for both. Cardioversion for one. Time with their families.

When 5 o’clock in the evening rolled around, the nurse thought to himself: If I were a good nurse, I would turn them more often. If I were a good nurse, I would clean their mouths every half-hour. If I were a good nurse, I’d spend more time with their families. If I were a good nurse, I would … It didn’t take long for his thoughts to lead him down the low road of self-doubt.

As critical care nurses, we often display some endearing traits. For example:
• We are high-achievers who border on perfectionism.
• We blithely take on responsibilities that seem beyond belief
to mere mortals.
• We buy into the thinking that good isn’t enough, that better will be just around the bend.

That may explain why this nurse, like so many others, let the benefits of self-awareness and reflection take him astray. He wandered down this unhealthy low road of self-doubt—an unhealthy path for him, for the nursing profession and especially for his patients and their families.

This nurse didn’t journey for long on this low road of self-doubt, thanks to one patient’s wife. After reviewing the day’s care, he asked if she had any questions, still thinking to himself, “If I were a good nurse, I would already have discontinued his pulmonary artery catheter.”

The wife stopped him dead in his tracks. “I always know my husband is getting such good care when you’re here. You always know what’s going on,” she said reassuringly. “I’m sure you know the right things to do and the right way to do them. And I appreciate that you always find time to tell me what’s going on.”

The nurse realized that he is “a good nurse” and that he is surrounded by great nurses, each bringing his or her unique personality and strengths to the bedside and to the care team. Some are technical wizards. Some are superb communicators and counselors. Others are highly intuitive. Even the less experienced bring optimistic energy and enthusiasm.

Our image of competent, always in charge, critical care nurses is often shattered when we see them headed for the low road of self-doubt. We are a group of extraordinary individuals who save lives daily, even hourly, and provide essential service to our communities. Sadly, because we’re high achievers by nature and have been socialized to go to extremes for our patients, we are vulnerable to self-doubt. Can we prevent, or at least nip this in the bud? I know I can if I:
• Give myself positive feedback when I’m doing a good job.
• Highlight the great work that my fellow nurses do. Become a regular user of my hospital’s employee recognition program to recognize their efforts.
• Compliment other nurses in public. Proudly brag to their colleagues and other team members about the wonderful job they did.
• Review my efforts and reframe them when a particularly challenging case has come my way. A patient’s peaceful and dignified death is often a triumph, not a failure.
• Make time to write a “formal” letter acknowledging another nurse’s truly outstanding work. And, remember to send a copy to his or her boss.
• Nominate others and myself for local, regional and national nurse recognition awards, including AACN’s Circle of Excellence program.
• Ask my patients or their families at the start of each shift what they’d like to make happen that day. Marie Manthey reminds us that every time we can help make something happen, we’ll feel great.
• Make time for a personal debriefing at the end of every work shift. Highlight what I accomplished by creating a “done” list, instead of a “to do” list.
• Acknowledge the gift of myself to the world and to myself. Melanie Chenevert’s wise advice still rings true: “Look in the mirror each morning [and whenever I take that much-needed break at work] saying over and over ‘I’m the best I can be today.’ ”
• Remind myself of the meaningful work I do. Whenever I hear myself start the familiar refrain of “If I were a good nurse …” I stop! Count to 10 and savor everything I’ve managed to do.

Early in my career, my first clinical nurse specialist wrote me a note to congratulate me on how I handled a particularly challenging situation. That note, which I still have, works wonders for me when I re-read it on a “down” day. I keep it with other reaffirming notes and cards that keep me focused on my journey of rediscovery—a journey where I’m looking in and finding myself, reaching out and helping others.

In case you wondered, I’m the nurse in the story I related at the beginning of this column. In fact, the 12-hour shift I described was just a few days ago. Have you experienced this type of self-doubt? What works for you, keeps you headed in the right direction and off the low road of self-doubt? I’d like to know. Your fellow nurses probably would, too.

Send your stories or tips to AACN News, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, aacnnews@aacn.org.

Letters

Treat Nurses Like Professionals
Re: “Nursing Shortage Foreshadows Crisis,” AACN News, July 2001:

I have practiced as a critical care nurse in a variety of settings for the past 10 years, but recently left to apply my experiences to indirectly enhancing the healthcare environments as a healthcare consultant. I did not leave nursing because of the schedule or because of the nature of the actual work. In fact, I love caring for patients.

I left because I could no longer care for my patients with the quality and continuity of care that I had established as a standard for myself upon graduating nursing school—and because I was unable to secure my financial future after 10 years of working. I no longer felt the support of administrators, including nursing administrators, when it came to defending issues surrounding patient care. Many of my colleagues turned their backs on issues surrounding patients’ and families’ rights. They also turned their backs on owning responsibility for patient care by not supporting hospital-based, independent practice issues or government legislation that would further enhance their practice opportunities. Instead, we have decided that the “union” suits us best for managing our practice and that nursing should take on a “blue collar” mentality.

I became a nurse because I wanted to work with a collaborative team, as a professional, to better care for my patients. I wanted to use my education to work both with a team, and independently, to provide care. Most importantly, I wanted to own my patient care. Good or bad, if I provided it, I wanted to be the one responsible for it, and not just between the hours of 7 a.m. to 7 p.m. We have lost that mentality in nursing, much to the detriment of our patients.

Sadly, I believe the nursing profession is moving backward. We have talked about this issue for years, but that is all we have done. Nursing administrators, on average, have not supported hospital-based protocols that would allow their nurses to work more independently, and healthcare facilities, in general, have abandoned ideas concerning reimbursements of continuing education for nursing in effort to cut costs, but at the expense of their staff development.

I am tired of trying to initiate change to no avail. I feel defeated and tired. Is it any wonder there is such a shortage.?

If you want to keep nurses at the bedside, allow them to work in a flexible, professional environment that also allows them to continually learn and contribute to the type of care they provide.
I commend your efforts in supporting solutions. I just hope you are not too late.
Erika Goss, RN
Allston, Mass.

Nursing Must Get Back to Basics
I usually do not comment on articles in your newsletter. However, I am compelled to respond to the nursing shortage issue. (AACN News, July 2001) There seems to be a great deal of damage assessment and intellectual conversation about the nursing shortage, but no one is bold enough to identify the true issues. Hospital administrations and the insurance industry, which are now in charge, do not concern themselves with the most important component of the healthcare industry—the human beings who actually provide the care.

I have 34 years’ experience working in a hospital and have noticed a deterioration in the delivery of healthcare, because each role is now driven to distraction by requirements regarding how we document our care. We are regulated to death—the demise of acute healthcare in general and certainly in nursing.

In South Carolina, registered nurses are not required to formally continue their education. I personally would not have survived 18 years in a cardiovascular ICU had it not been for my affiliation with AACN. I am the founding president of the Upstate Chapter of AACN in Greenville, S.C., and have been CCRN-certified since 1984. I cannot imagine any critical care nurse not participating in this standard. And, I cannot respect any hospital that does not encourage participation in the organization.

However, the hospital does not support any speciality certification and continues to float inexperienced nurses into the critical care units. The “warm body” philosophy of staffing is the only one implemented. If patient acuity was actually matched to nursing skill level, there would be more “closed beds” across the nation than the few here and there that we hear about.
I no longer work in the ICU, because I was told to work 12-hour shirts or leave. My name was taken off the schedule.

I am still a CCRN, but found employment on a medical-surgical floor, working eight-hour shifts. Our floor has eight telemetry beds. Although the secretary’s job description includes monitor tech, we really have no monitor tech. Many of the nurses are not “dysrhythmia certified” and, admittedly, do not know what to do when a patient goes into ventricular tachycardia.

In reality, there may not be a nursing shortage, but instead an abundance of circumstances that are negatively impacting the profession. Even the nursing organizations cannot agree on what should be the entry level for nursing. Things are so out of hand that no one really knows what a standard of care is.

We must get back to basics. Nurses need to be doing nursing, not care plans. Not cleaning. Not bulletin boards, Not charge audits. Not inventory.

I am not impressed by how our profession has been driven to distraction to the point at which the profession is no longer recognized for the superb profession that it is.
Betsy Turner, RN, AA, DSN, CCRN
Greenville, N.C.

Nurses Need Better Pay
Re: “Nursing Shortage Foreshadows Crisis” (AACN News, July 2001):

AACN should be lobbying for adequate funding of Medicare for hospitals. This would increase RN salaries and increase the availability of nurses.

As an older nurse in critical care, I have seen the continual loss of younger nurses. What do they want? The answer is better pay. That’s why so many nurses are going back to anesthesia school.

Why can’t AACN work on the real problems, instead of trying to just increase funding for education and scholarships? I am also beginning to wonder if unionized nursing is the only way to get better pay.
Alan R. Dekerlegard, RN, BSN, CCRN
Youngsfield, La.

Editor’s note: Besides supporting funding for education and scholarships, AACN recommends in-creased work force funding for the Department of Labor and the Health Care Financing Admin-istration, as well as for other agencies that serve to ensure an equitable safe and fair workplace. In addition, AACN is engaged with other healthcare organizations in a major campaign to underscore the importance of nursing’s contribution to healthcare and patient well-being. An emphasis on pay, as well as other workplace issues that continue to be identified as dissatisfiers to nurses, is a top priority for the organization.


Davidson

My Turn: The Dangers of Teenage Drug Use: A Recipe for Easy and Rewarding Community Service

By Judy E. Davidson, RN, MS, CNS

Have you ever wanted to do community service related to nursing, but didn’t know where to start? Have you ever cared for a young patient who died from an overdose and thought to yourself, “What a waste, I wish kids knew how dangerous fooling around with drugs really is!”

When our local chapter of the federally funded Safety and Wellness Advisory Commission (SWAC) asked me to speak to parents and teachers about the dangers of drug use, I felt unqualified and tried to decline. SWAC representatives assured me that, if I had ever seen someone die from an overdose,

I had what it took to do the job.

Using the National Institute on Drug Awareness (NIDA) Web site, I began researching some of the drugs on which we had seen patients overdose. Then, I patched in a couple of real-life “horror stories” from the workplace to prepare for the talk. As a part of the National Institutes of Health, NIDA is an excellent resource for materials, including teaching templates and student-appropriate visuals. The NIDA Web site is www.nida.nih.gov.

Since the first presentation, I have been invited to speak directly with students, repeat programs at other high schools and church groups and have also been asked to help a group of teens develop a video on the dangers of drug use.

Drug awareness community service involvement was easy, well received and very rewarding. I would recommend it to anyone. In fact, I would be willing
to share the slides I have developed with anyone willing to try it.

The following is an outline of the topics I cover in a one-hour lecture on the topic:
• Horror story #1: Girl dies from accidental overdose: Soma
• Horror story #2: Boy dies from accidental overdose: GHB plus alcohol
• Myths leading to unintentional self-harm
• How the “high” happens
• How the “high” backfires
• About club drugs
• Recreational use and dangers of over-the-counter drugs and their dangers
• Recreational use and dangers of prescription drugs: Soma
• Recreational use and dangers of inhalants
• Suicide/suicide risks
• Drug identification in teens vs. other age groups
• The link between rape and drugs
• Strategies for prevention

I shortened the talk to 20 minutes for younger audiences. Of course, if you were making the presentation, you would substitute your own real-life stories. The people at SWAC can help you to find an audience and will also assist with slide development and copying outlines. You can contact SWAC at swac@mhsinc.org, or call (858) 391-9303.

Judy Davidson is a clinical nurse specialist at Pomerado Hospital in San Diego, Calif. She can be contacted at Jed2@pphs.org.


Care and Compassion Are Hallmarks of the Quality of Care Provided

Editor's note: After the Spokane Review published an opinion by a 19-year-old Eastern Washington University pre-med student, lamenting the inadequate care her grandmother received from doctors and nurses, AACN member Lori Feagan, RN, ADN, responded. The student had taken the medical profession to task for what she perceived to be the uncaring way it cares for the elderly. Her grandmother’s illness, which had been misdiagnosed, was followed by surgery that came too late and an infection that ended up contributing to her death. Following is the “Perspective” article Feagan wrote in response.

The anger expressed by this woman about her grandmother’s care should remind all of us at the bedside that every word, every expression, every touch is interpreted in a different light by those who may be experiencing the most catastrophic event of their lives.

Sometimes doing our jobs well means standing back, perceiving need, anticipating grief, closing a curtain, turning off a monitor, providing quiet. It also means allowing for cultural, social and religious variances.

In our ICU at Valley Hospital and Medical Center, we have burned grass for Native Americans, lit candles for Romas, had church choirs sing and congregations crowd into rooms to send their pastors to God in prayer. We hold the hands of the dying when it’s too much for a family to bear, bring babies in for first hellos and final goodbyes. Every hospital has its own policies, but it’s the nurses who make the difference.

Learning patients’ needs beyond the physical is something that develops with experience and professional maturity.

The events leading to the death of this woman’s grandmother were tragic. But no family should feel “at the mercy of institutions.” Had this terrible series of events been followed instead by steady recovery and eventual wellness, I wonder if the perceived errors and uncaring would have been forgiven.

A reminder to healthcare consumers: You have an obligation to seek clarification, opinion and, if necessary, alternatives if you believe you are not being heard. Don’t wait days, months or years,
if the trust you’ve placed in your provider is fading. This is your life. Patient responsibility and patient rights are intertwined.

The woman quoted from an article originating in Britain, a country where socialized medicine dictates who receives intervention and at what level.

This is America and, here in the Inland Northwest, you can enter any hospital regardless of age, income, race, gender or religion and receive uncompromised access to healthcare.

You have the right to accept or refuse treatment to the extent permitted by law and be informed of the consequences of your actions. You have the right to choose your physician and ask for other opinions. You can also ask to speak with a supervisor should you have concerns regarding your care.

I am concerned that, based on her sole experience, this woman has concluded that hospitals, physicians and nurses lack compassion. If not for compassion, we could not do what we do. During my career as a critical care nurse, I have worked in three of Spokane’s hospitals and have had the honor of working with the best that nursing has to offer. When a family is experiencing great sorrow, a nurse will remember one of his or her own, and respond with the compassion born of familiarity with loss and grief. It happens every day and we keep coming back.

The public should not be outraged that sometimes, despite our best efforts and most advanced technology, there are sad endings in hospitals. However, many devastating illnesses have positive outcomes. This woman’s claim that the elderly are provided substandard care is utterly false. Medical neglect of the elderly is not usual, nor does it “occur more frequently than people realize.” The reasons surgeries are not at times recommended for the elderly range from high mortality risks due to underlying heart, lung or kidney disease, to quality-of-life issues and end-of-life decisions, which are made by patients and their families, not by physicians or nurses.

Medical advances have allowed for longer lives, sicker patients and tougher decisions for patients and families. It is the patient and family who must decide when “enough is enough,” otherwise all options are considered and used, regardless of age or life expectancy.

Tenderness, respect, integrity, dignity are words that express what one word encompasses best. That word is care. It is what we do every day.

With as much passion as her grief inspired, I have to say just as passionately that I’m so sorry your grandmother died, but you are wrong. Your personal experience is not the standard by which you should judge all others. If you want to guarantee compassion and excellence in your future, stick with med school.

Or, better yet, become a nurse.