12/11/17

The dumbest or biggest waste of time someone has checked into the ER for?

The common cold? Hangnail? What are some of the most ridiculous moments you've encountered of grown adults coming into the ER, tying up resources, you've experienced?

11/28/17

Have you, or when was the last time, you lied to a patient or their family?

Have you ever been in a circumstance where you lied to a patient or their family? There may come a time when you are trying to relay information and the family doesn't comprehend what's happening, and you may, say, save someone's feelings with a white lie. Are there instances where it could be for the better, to help families or patients cope with loss. here's a story from Allnurses.com worth reading. Warning, it's a tear jerker.
I got the call on the EMS radio around 5 am. This is the usual time we get calls from EMS responding to nursing homes- The nurses are rounding on their patients to give am meds, and they find their residents dead or in distress. An 87 yo female, febrile, and in severe respiratory distress coming in. Pt is a DNR, but family is very involved, is aware, and will meet them in the ER. I'm alerted that family is in the waiting room before the patient even gets there. I go out and introduce myself, tell them I will be her nurse, and that I will bring them back as soon as I get her settled in the room. EMS arrives, and carefully transfers their frail burden onto one of my stretchers. You can see the relief on their faces, that they got her here and are able to hand her off before she dies on their watch. I'm now the proud owner of one very ill person. Temp 102+, Respiratory rate 14 and irregular. HR 50's, sat 84% on NRB, I don't need my Littmann to hear the rhonchi- Other hx is advanced dementia, DM, CHF. Has been in the nursing home for about 6 months- her husband had taken care of her at home as long as he could, but it finally got too much for him to manage, as he was also dealing with his own health problems at the age of 92. I got her settled, and the Doc comes in- I give him the pertinent info- Not a whole lot we can do at this point other than make her comfortable and treat the infection. Chances are poor that she will make it, and we both know it. Doc moves on to deal with people he can help, leaving me in control of this mess. I bring her visitors in, including her only daughter in her 60's, and several close friends of the family. I get them settled in and TRY explain to them what is going on. They don't get how bad off she is- I try to explain it to them in soft terms- They share with me who she is- a wife, a mother, a friend.I learn her husband is frail and elderly. I strongly suggest that if he is able, that he come. The daughter tells me she is going to leave to go get Dad. I explain that mom could go at any moment, each gasp she takes could be her last. I don't want them to have to deal with the idea that she died without ANY of her family around. But I REALLY wanted her husband there. The daughter calls her husband, who is dispatched to go get him dressed and here. In this age of technology, we can keep up with a lot of things. I'm updated that son in law is at dad's house, he's getting him dressed, getting him loaded in the car with the wheelchair. I'm watching my patient brady down, 50's, 40's 30's....The monitor is alarming, and my pt.'s daughter sees it. Husband lands in the parking lot, and the son in law is getting him loaded in his wheelchair. Then she died, no resps, asystole on the monitor. The daughter asks me- "Is she gone?" ..... Read the rest here: http://allnurses.com/emergency-nursing/i-lied-a-960234.html

11/7/17

Nursing Practice During a Disaster: Some Considerations

Nursing is by nature a profession based on caring compassion and the desire to alleviate suffering and facilitate healing. The nursing profession has and will play a vital role in the response to any disaster. This fact has been acknowledged by the Institute of Medicine(IOM) in their report The Future of Nursing Leading Change and Advancing Health. The IOM has also created the report titled Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations. The nation has coped with disasters such as the 9/11 terrorist, hurricanes, and pandemics. Some disasters require an all out immediate health care response, other disasters require a more planned response over a longer period of time. The IOM has distinguished disasters by calling them pervasive or catastrophic. However, every disaster requires a different allocation of resources, and maximum output of health care personnel. Care decisions are made in a compressed time frame and the standard of care will change. The standard of care that is able to be implemented is known as a crisis standard of care, is executed by the presence of certain circumstances and at present is formally declared by a state government. Preparation before a disaster is essential. There are many questions that nurses would have in deciding how to respond in a disaster. What are a nurse’s professional and personal considerations? Effectiveness means getting the answers beforehand, as almost any nurse will feel a professional obligation to assist in a disaster if needed. This article will pose some questions nurses might have in an attempt to provide tools to help a reader make an informed decision. The IOM has recommended national standards and protocols in any disaster response. Currently only some states have disaster contingency plans. The IOM with input from professional organizations such as the ANA has prepared a report that outlines suggested procedures. The ANA has its own policy paper as well. The Red Cross is also establishing scope of practice for nurses in their disaster response which includes nurse managed shelters. It is called the Disaster Health Services Concept of Operations. The IOM has stated that 5 elements must comprise any national policy on disaster response. They are: That any plan has a firm ethical foundation, and there be community and provider engagement and education that are continual and integrated. There must be assurances on legal authority and environment. Clear triggers, indicators and responsibilities, which employ evidence based decision making processes.are necessary. Here are some of the questions nurses might have about their professional role in a disaster. What capabilities will I need to practice effectively? The Columbia School of Nursing has composed a list of core competencies for clinicians in disaster healthcare. For a health care professional the following is a brief summary of emergency preparedness skills: Responding to the emergency within the incident or emergency management system of the particular organization or entity. The ability to explain one’s role in the disaster response. Initiate patient care according to licensed ability and coordinate referrals to an appropriate agency according to the patient’s condition. Be able to recognize sickness, disease, or injury that is a consequence of a number of agents natural or manmade. The ability to put in place infection control procedures to reduce spread of disease, which will include decontamination and use of protective equipment. Recognize and manage stress and anxiety created by the disaster and refer if necessary. Communication is a large part of several competencies as clinicians will need to both receive and convey information about the disaster, for example to facilitate updates. They will also have to interpret information received and summarize care given to patients and also participate in post event evaluation. What would be my scope of practice? What the legal protection is in place to protect me in my practice? The IOM report stated that professionals need to be clearly protected in order to allow health care professionals to practice without fear of legal action as long as they are acting in good faith and not recklessly. Although comprehensive liability protection is in place medical personnel are protected if they act under an emergency declaration as part of a team, for example. The IOM has recommended that existing liability protection be tied to linked to the declaration of crisis standards of care. An ethical foundation allows for confident provider response and action. Clarification and standardization of protocols will encourage nurses to respond in a disaster. If my present employer doesn’t have a disaster plan response where can I get training in disaster nursing? Be knowledgeable about your employer’s emergency preparedness plan if your medical center has one. Get involved in advocating to your peers the importance of creating a plan. Also be aware of your state’s response protocols are. Nurses can also train with organizations that would respond in a disaster such as the Red Cross, Disaster Medical Teams and the Medical Reserve Corp Standards of care in a disaster will differ from health care on a regular basis. Any crisis standard of care must be applied consistently and with transparency. All this must be contained in a policy that has been developed pre disaster by a disaster medical advisory team using evidence based decision tools and algorithms. In a disaster health care professionals’ goal must be to provide the care for the greater good of a larger number of patients. Nurses must confidently rely on their professional experience to make up for the lack of technology, staff, or support services available. Also utilities and infrastructure to administer health care may be damaged. One point that has been proven in any disaster is that vulnerable groups of society suffer the most both during and after the event. As mentioned earlier, community engagement is necessary in any disaster response plan, both for it to be executed successfully and for the recovery of citizens after. This is where nurses’ professional skill and unique position of trust in the public’s eyes will mean they are the health care professionals best positioned to elicit and maintain constructive productive dialogue with the public before, during, and after a disaster. Policymakers would do well to note the public’s trust in nurses and put them in positions to engage the public in disaster response planning. Sources: http://nursingworld.org/MainMenuCategories/WorkplaceSafety/DPR/Disaster-Preparedness.pdf http://nursingworld.org/MainMenuCategories/WorkplaceSafety/DPR/TheLawEthicsofDisasterResponse/AdaptingStandardsofCare.pdf http://www.nap.edu/catalogue/12749.html http://nursing.advanceweb.com/News/National-News/Nurse-Led-Disaster-Response-Model-Aligns-Red-Cross-With-IOM-Goals.aspx?cid=xrs_rss-nd

10/16/17

Burnout - From the ER and Beyond, Healthcare Workers at Risk

With a rising awareness real mental health, one of its aspects seems to lack practical application in the workplace. Nursing, and healthcare professionals, know that their job is fast-paced, sometimes at break neck speed, role that demands significant focus and investment in all ways. That includes mental and physical weight that can have adverse effects if nothing seriously. We have seen many healthcare professionals, not the least of which are nurses, have to take long extended leave, or worst, leaving the profession entirely because of burnout. The question for discussion is this: How does your workplace treat burnout? The startling reality is that burnout happens, and you need to take care of yourself. However, workplaces seem to ignore this reality and do not have adequate mechanisms in place to help their employees. The culture of overworking is one that's leaving unhealthy nurses in its wake. Are there programs in your workplace that are helping? What have you seen work? What do you do for yourself to ensure holistic health?

5/4/17

Mental Health Awareness and Care for Nurses

It's mental health awareness month in the US, and mental health awareness in Canada.

There's a noticeable increase in mental health awareness. For example, it's helpful when celebrities step up and share their struggles. It normalizes what has largely been either hidden or stigmatized.

Mental health is something many health practitioners know intimately. Both in what they see on the job, but also what they what they have to deal with themselves.

If, as a health practitioner, and especially a nurse, you don't take care of your own health, you're going to suffer. Faced with acute issues normal in a healthcare setting, like a hospital, increases the likelihood of mental illness.

High stress environments are a normal part of the job. However, the consequences of that environment need to be treated as normal too. Often, the results of losing work time and employees to issues such as anxiety impact the healthcare delivery system as a whole. What's both disappointing and incredulous (if you're the healthcare practitioner) is how little management acknowledges the problems.

From management, to corporations, to insurance providers, to workplace safety, mental illness still has a ways to go before it is recognized as in need of both proactive treatment (self-care), and space for healing (when illness emerges).

How many nurses, for example, suffer from mental illness yet can't claim that as a viable health concern to receive time off and insurance coverage for that time? How many are wondering if they're they only person who suffers from workplace anxiety because the issue is simply not addressed by management. How many are faced with management or environments that simply assume you work until you burn out and then are replaced?

The holistic care for employees in the healthcare, especially doctors and nurses, is lacking. We need to use the increase in mental health awareness to raise the prominence of adequate services and policies to protect workers as they continuously provide services in areas with a high degree of impact on one's own mental health.

What are do you do for self care? Share your insights.

What do you receive or see happening in your workplace both positive and negative?

5/1/17

Nurses: You are Intrepid Pioneers



The knowledge and skills of nursing are portable and reflect versatility. Nurses are scientific critical thinkers who see their vocation as a calling to improve the health care of citizens through compassionate healing. Nurses’ ability to evaluate and think on their feet in a variety of situations is found in all locations of health care from the operating room to patient homes.

The history of nursing reflects innovation. Since May is the month we find nursing week this article will take a look at one aspect of the future of nursing. Nursing’s bird’s eye view of health care gives nurses opportunity to see how health care delivery can be improved through new inventions of equipment and services. There are many examples in the past of nurses who have filled voids in the health care system by pioneering health care innovation. They have been mentioned in this space already, such as Frontier Nurse Services or the Visiting Nurse Services of New York and the Henry Street Settlement.

Some nurses have extended the entrepreneurial spirit to create businesses of their own. This article will give several examples of present nursing businesses and possibilities in the future.

4/18/17

The Horror Stories of Clinical - Student Nurses Share Their Experiences

All nurses have them. At first, it was a shock, but if you stuck with it, you realized it was going to be a routine affair. We're talking about the chaos of humanity you can only find in healthcare.

Although not specific to the ER, sharing stories about your time in clinical (especially if you're in the midst of it now) is a good cathartic release for what can be heavy stuff. Here are two anecdotes to share. If you have an experience from your time in clinical or internship, (hopefully with levity) add it to the comment section below.


2/13/17

Work Abuse on Nurses: Seven Mondays in a Week: The Consequences of Society’s Decline in Civility

Would you look forward to work each day if you knew there was a possibility you would be verbally or physically abused?

Emergency departments are experiencing an increase in use by the public. Hospitals are unable to keep up. An analysis of this use points to one unintended consequence of a non universal private health care system. The emergency department of a hospital is the only location in an overburdened health care system where any patient who shows up must be treated regardless of ability to pay. With state facilities and programs for mentally ill citizens, and those suffering drug addiction being eliminated these patients often end up in emergency wards. Visits to emergency departments(ED) for alcohol or drug related incidents are on the rise.

Emergency departments are often overcrowded. Overcrowding is defined as all beds in use and the waiting room full for more than 6 hours a day, patients placed in halls, and seriously ill patients having to wait more than 1 hour to see a doctor. (1)
Long waits are more then rule than the exception. Add sickness, trauma, mental illness and drug use to the lack of privacy, and a less than ideal situation is created for patients to appropriately cope with stress.

Nurses who execute care and spend the most time in triage and treatment suffer the brunt of patient and family frustration. They are subject to verbal and physical abuse at unacceptable rates. Studies have shown that health care workers are the most likely to suffer workplace violence after prison guards and police officers. In a profession where healing and mercy are requirements it is disturbing that nurses are subject to these assaults.

Nurses are abused verbally by been sworn or yelled at, or called names. Physical violence includes being spat upon, scratched, hit, slapped, kicked, or stabbed. Injuries can range from the not visible to months taken off work for severe injuries.

The Emergency Nurses Association believes that violent incidents are underreported according to a recent survey. Nurses often don’t report incidents. They fear it will reflect badly on them as being less than competent. Or they believe that the administration will not take them seriously or be indifferent. They do have some basis to believe that as up to 75% of medical centers do not respond to reported workplace violence. Also many institutions do not have workplace violence policies or prevention programs. Nurses also believe that abuse by patients and families are part of the job. In some cases they can empathize with the scenario that created the violence. Often they believe if they press charges that the perpetrator will escape conviction because they were mentally ill or high on drugs.

 Nurses associations are advocating to end violence against nurses. The Pennsylvania Association of Staff Nurses and Allied Professionals had a conference in early November, Massachusetts Nursing Association is one that has done a lot of work in raising awareness. The Occupational Safety and Health Administration office has issued guidelines for medical centers to address this challenge. However, these guidelines should become enforceable standards. The survey shows that hospitals with a zero tolerance workplace violence program have less than half the number of incidents of other medical centers that have no policy.

In Massachusetts, a House representative and a senator have introduced an act requiring Health Care Employers to Develop and Implement Programs to Prevent Workplace Violence. 26 states now have more strict penalties for assaults on nurses. New York very recently made assaulting a nurse a felony same as assaulting a police officer, firefighter, or EMS personnel. In contrast, 2 states that were going to move these assaults from misdemeanor to felony killed the proposal. Another state deferred the decision. Even in hospitals where severe assaults have disabled staff, the administration has only struck committees yet have failed to disclose when the committee would meet or the results of the meeting.

Prevention and being proactive are the keys to meeting this challenge. If administration is committed to training all staff and encourages reporting of incidents there would be progress towards prevention. Administration must also be committed to having adequate staffing levels at all times in the ED. Several bodies such as the American College of Emergency Physicians and the International Association for Healthcare Security and Safety, have made recommendations such as yearly risk assessments especially if the hospital is located in an area where there is high crime or gang activity. If it means having metal detectors and visitor sign-in those should be put in place as one hospital in Detroit did. Why would anyone need to bring a gun or a knife into the ED?

In the Institute of Medicine’s(IOM) report in 2007 on emergency care in the US they commented that that crowding, boarding, and ambulance diversion were the total opposite of high quality medical care. The Joint Commission for Accreditation of Hospitals had tried in 2004 to institute strong measures to counteract these now common practices but pressure from hospitals caused the measures to be watered down. In no uncertain terms the IOM’s report recommends that these measures be reinstated. Decreasing crowding, boarding and ambulance diversion would go a long way to dealing with ED violence and allow high quality emergency care. The violence is only a symptom; the root caused must be addressed.

One interesting fact is that less than half of ED patients require urgent care. To reduce wait times hospitals are considering NPs to treat non urgent patients.

The Ed puts a microscope on societal attitudes to nurses, health care, and especially violence. The examination is not pretty. Why do patients feel they need to act out their frustrations on someone that will ultimately help them get better? Why aren’t hospital executives proactively seeking to prevent violent incidents? The IOM notes that hospitals have no financial incentives to reduce ED crowding.  Are numbers and dollars more important than patients and staff safety and well being? Has society become so desensitized to assaults that it is seen as an inevitable part of life? How can anyone tolerate that a nurse can be abused on the job? Acceptance of the unacceptable says a lot about the people that have the power to change it.

Notes:







1/9/17

The Preparation of Nurses to Enter Complex Practice



The unprecedented need for more nurses has led to an examination of the state of nursing education in the nation. This article will present several recent views that discuss both the need for a greater number of nurses and increasing the quality and relevance of nursing education.

A number of factors are preventing nursing education from reaching its full potential.  Nursing education has not changed significantly in the last half century. Clinical training availability is of paramount concern. RNs typically have little financial incentive to leave clinical nursing to become instructors. Half of all present faculty will retire within this decade. They are not being replaced at the same rate and yet there will be a need for even more instructors quite soon.

It has been suggested that the many ways to enter nursing does not encourage enough graduates to continue on past the ADN or BSN therefore missing the opportunity to become instructors.  Without faculty, potential applicants will not become nurses. Unfortunately, many thousands of applicants are turned away yearly.  How to correct this situation?

In Educating Nurses A Call for Radical Transformation Patricia Benner set out to investigate present nursing education with this question: Are nurses graduates adequately prepared to practice to their maximum potential? The answer she found was no. There were strong points in present nursing education but areas where changes could be made. This is not entirely because of any shortfall of nursing education. There are pressures, challenges, and issues that place unprecedented demand on the nursing profession. Many of them originate outside of the nursing profession.

The first challenge is the state of professions in general. The author mentions that one hallmark that distinguishes professions from other career paths is it’s sense of social responsibility. Professions must advance society’s good. Yet in recent decades society and therefore the professions have placed more of an emphasis on technical knowledge and adherence to the business model. Health care professions and nursing have not been immune to this philosophical shift in the professions. Nurses must often feel caught between their core values and fulfilling the bottom line, especially given that much of health care in the nation is private and for profit.

The turmoil in the health care system does not create the ideal environment for nurses to be adequately prepared on graduation. Turmoil and change can often result in philosophies that deal with crises in a short term way, often sacrificing long term vision as a result. For example the enormous need for more nurses puts pressure on educational institutions to lower admission requirements and to fast track students to achieve the numbers over quality. That urgency will only increase this decade, so nursing education needs to transform as Benner stated.

What does this transformation look like? She emphasizes the importance of integration of the 3 foundations of nursing education.

All three foundations must be integrated and not taught in isolation. The first foundation is nursing knowledge and science. Yet the acquisition of knowledge is not the end goal. Learning must be experiential, situated coaching in a community of practice. She stresses clinical reasoning and teaching for a sense of salience which she describes as gauging what is important to know and do for a patient and his/ her particular situation. It is knowing how to use the knowledge the student has acquired. Health care is unpredictable and open ended so the student must be able to evaluate what is the best course of action. She cites 2 examples of this from her interviews with instructors:

The student didn’t realize that 7 days was too long for a patient with an appendectomy to be in hospital. So they examined the patient and took a better history. Although they looked at the report it wasn’t as thorough as it could be; it did not provide any clues. Through investigation they discovered gangrene in his colon; that was why he was there so long.

In her second example a supposedly stable patient was deteriorating rapidly. Yet the staff nurse responsible for the patient did not think the changes warranted action. The instructor insisted the patient should go to ICU. She engaged the student by asking her What one test could we do to prove the deterioration? They decided on the blood gasses test which was done immediately. The test showed the patient needed to go to ICU.

 The last pillar is ethical formation and ‘comportment’. Formation involves looking beyond technical skill of the profession to the moral content eg obligations and demands which involves character formation. For instance when students see less than ideal practice that involves nurses treating patients badly how does one deal with that as a nurse?  How does a nurse help peers look at their practice to make positive change? Is that possible when in the beginning one doesn’t have institutional authority? Can a nurse help make changes in the professionalism of their peers? What about when a patient refuses a simple life prolonging intervention?

At present only around 20% of ADN graduates go on to the BSN. This is in part due to the time it can take to get any degree, which is time taken away from work and family. The goal of articulated programs is to streamline the process from ADN to BSN and beyond.  Regional innovations in nursing education are addressing this challenge. One of them is the Oregon Consortium of Nursing Education. Schools in Oregon have partnered to first of all envision the type of nurse that the population would need. Building on this vision they created a common curriculum and share resources. The consortium is committed to ongoing faculty development. City University of New York has received a Robert Wood Johnson Foundation grant for their program.

Because nursing practices in the space between medical diagnosis /treatment and the patients experience of wellness and illness a nurse requires both technical knowledge and expert relational skills. The education of nurses must prepare them to be lifelong clinical learners.

As one student said: “I have the honor of being present with and learning from patients in intimate, vulnerable, scary situations. I get to regularly advocate for the underserved in the hospital setting. I have access to environments I would otherwise never been exposed to, I have learned, grown and broadened my world perspective. I better understand how our system works and hope some day this knowledge will help me make changes in the system.”

Health care systems and society must recognize that improving education of nurses is a high priority. But nurses must take the initiative if they do not.

Educating Nurses: A Call For Radical Transformation. P Benner et al. The Carnegie Foundation for the Advancement of Teaching 2010 Jossey Bass