We Need More Nurses: Working Together

June 3, 2015 / Olga F. Jarrín / 2 Comments

Filmed nearly 40 years ago, the “Politics of Caring” film provides history of the grassroots support groups and activities that we continue to build on. One of my favorite parts of the film is about 5 minutes in, when a group of nurses are discussing their frustration with hospital working conditions: “We don’t have enough staff, we don’t have enough time…” They talk about wanting to improve their working conditions, by moving to a different hospital, or unit, or leaving the hospital to work in the community described as “mecca”.

When I graduated nursing school it was not uncommon for nurses to regularly care for 8 or even 10 patients on a cardiac surgery step-down or transitional care unit. I knew this was not the way I wanted to practice nursing, and found my passion in community and home health nursing. The 2003 NurseManifest Study provided an opportunity to talk with my co-workers and colleagues locally and nationally, to better understand what changes were needed and desired by nurses to create their ideal working conditions. Some of the major findings were that nurses felt a lack of respect, a lack of voice, and a lack of unity. Now, over a decade later, my work is dedicated to research that tells the story of what it is like to practice nursing today, and that shows the value of nursing for patients and society as a whole.

Why everyone should care about nurses’ working conditions and staffing ratios was the subject of a recent New York Times Op-Ed “We Need More Nurses” by Alexandra Robbins. The op-ed piece mentions dozens of research studies providing the evidence that patients’ risk of death, infections, complications, falls, hospital and hospital readmission are greater when nurses are caring for more than 4 or 5 medical or surgical patients. Hundreds of readers’ comments brought personal stories and richness to the conversation from the views of nurses, patients, family members, physicians, administrators, and more.

Working conditions and labor force issues for nurses is an international priority, and one source of current information is the RN4CAST Consortium, consisting of nursing workforce research groups in 17 countries, including the United States. Currently the United States group, based at the University of Pennsylvania, is surveying over 250,00 registered nurses and advanced practice nurses about nursing care, patient outcomes, and general working conditions for nurses. You can learn more about their work, and the study director Dr. Linda Aiken here.

Another source of information and place for collaboration is National Forum of State Nursing Workforce Centers, comprised of nursing workforce centers in 33 states. The National Forum of Nursing Workforce Centers is a resource for finding information specific to your state, as well as about nursing workforce issues nationally. Their annual conference will be held next week in Denver, Colorado and you can download the conference brochure and registration information from their website.

Trans* Health in Practice: Simple ways to be welcoming, supporting, and caring with the non-binary community

May 20, 2015 / monashattell / Leave a comment

Lavender Health - LGBTQ Resource Center

Co-authored by Candace W. Burton, PhD, RN, AFN-BC, AGN-BC, FNAP assistant professor at Virginia Commonwealth University, and Monica McLemore, PhD, MPH, RN, assistant professor at the University of California San Francisco.

This week the United State Supreme Court hears arguments in Obergfell v. Hodges, a case that could determine the fate of hundreds of same sex marriages across the country. Even as our attention is drawn to that high-stakes process, it’s critical to consider how we can create an inclusive space in our own lives, work, and communities. One means of doing so is to recognize and attend to the needs of trans* and non-binary gender individuals in health care practice. As three nurses who work in mental health, reproductive health, and emergency care, we encounter people all along the gender spectrum and strive to provide safe, effective, and nonjudgmental care. We also understand that institutional-level change occurs about…

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Peace and Power as a Relational Leadership Handbook

April 13, 2015 / Peggy L Chinn / Leave a comment

This wonderful account of “Peace and Power” by Adeline Falk-Rafael has just been published!

Peace & Power

Writtten by Adeline Falk-Rafael, PhD, FAAN, Professor, York University

For the past 4 years, I have taught a 4^th year leadership course to Internationally Educated Nurses (IENs), who are in our RN-BScN program at York University in Toronto, Canada. The course is designed to support students to meet professional standards of leadership in whatever position they practice and to provide them with beginning knowledge and skills required for nursing leadership, particularly at the bedside, but applicable in positions of

Adeline Falk-Rafael

leadership as well. The course reading materials include 2 “textbooks” – one that focuses on leadership (not management) and Peace and Power. My use of Peace and Power began simply as a process to use in the classroom, as I had in other courses for years. In reading it simultaneously with leadership literature, however, I began to see the strong relationship of its tenets with relational leadership…

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Futile Care: Alive and Well in America

March 19, 2015October 4, 2017 / Carey S. Clark, PhD, RN, AHN-BC, RYT, FAAN / 3 Comments

Contribution by Carey S. Clark, PhD, RN, AHN-BC

I recently supported a dear friend of many years who was faced with caring for her terminally ill husband. We were part of a small group of fast friends, having all gone to the same college, and we spent many years afterwards celebrating life and adventuring together. In many ways, this special couple had been family to me over the years.

One challenge for me as a nurse was being 3000 miles away and relying on text and cell phone calls to assess my friend’s status and prognosis. While I was fairly certain that once he was put on the ventilator, given his complex medical situation,he had numerous ailments that were too complex to be treated at home one of which was leaky gut. Not even a nurse coming to the home would have been able to give him the care he required. He would not be successfully extubated and go on to be discharged, the medical staff were not clearly communicating this to my friend who was trying, despite her grief and stress, to make the right decisions for her husband.

The conversations I had with my friend ran deep, and the main challenge was supporting her in getting the prognosis clearly from the various providers; my biggest questions for her to answer to help support my assessment were why is he still on the ventilator, what is the prognosis, and what did he want medically at the end of life? It turns out he wanted all medical-technical interventions possible if there was hope for his recovery and some quality of life; but what was not being conveyed clearly here was the hope of recovery issue.

After several days of the husband being on the ventilator, my friend was able to listen to the renal team discussing her husband’s care, and it became clear to her that he was not being “cured” or healed, rather they were prolonging his inevitable death. The hospitalist was in a little bit of opposition to the renal team, with the hospitalist wanting to continue care, play wait and see for a little while longer. My friend recently reflected that the hospitalist was okay with simply keeping her husband alive, with no apparent concern for his quality of life. Finally, when my friend’s husband became septic a few days after intubation, when the full team finally confirmed that the prognosis was extremely poor, she was able to make the decision to remove the life support. He passed away peacefully shortly thereafter.

Unfortunately, this scenario of futile care and over-use of technology at end of life is repeated over and over again, on a daily basis, in nearly every hospital in America. While we know that technology use can save lives, we also know of the pain and suffering it can cause. For instance, Johns Hopkins recently reported that fully 30% of people intubated in the ICU setting suffer from PTSD post extubation. When people state that they want everything done for them if there is still hope, we need to consider that folks may really not know what they are consenting to, the suffering that technology in futile care cases can create, or the improbability of recovery after undergoing a full code scenario in the hospital. Their knowledge and experience with end of life technologies is often limited to what they see on TV or in the movies, the heroic efforts, the beautiful deaths, the rapidly unfolding peaceful or positive conclusions that bare little resemblance to the reality of end of life care.

As healthcare providers, nurses and doctors do know. Most doctors clearly do not want aggressive technologies used for themselves, and yet they need more training on clearly communicating when care is overly-aggressive or clearly futile; the following article clearly summarizes the research with doctor’s preferences around technology at end of life and the sort of training both doctors and nurses need to do to support better end of life care. http://www.healthline.com/health-news/end-of-life-treatments-doctors-patients-differ-060314#3

As Dr. Angelo Volandes in his Boston Globe Opinion article stated, we need a complete overhaul of end of life care in this country. “I have heard patients and families demand that we “do everything,” to prolong their life, but in many cases they, unfortunately, have little idea what “everything” means because no one has explained their options clearly. Sometimes, patients and families don’t want to face death. But more often, the problem lies with the medical profession. The principal reason we have gotten death so wrong is because doctors fail to have meaningful discussions with patients and their families about how to live life’s final chapter.” (Read the full article here: http://www.bostonglobe.com/opinion/2015/01/11/prescribing-end-life-conversation/GfhqbsYR8KjaD3ePWlK6JI/story.html).

Unfortunately, it remains true today that approximately 60% of the population in America will die in the hospital, even as we know 80% of folks would prefer to die at home. Meanwhile, the media generally continues to portray death inaccurately. In our culture the general public has little to no opportunity or incentive to educate themselves around death, and yet it is where we are all headed. Although it may be “easy” or “correct” for nurses to go along with doctor’s orders and provide futile care day after day, at what point do we decide to do our care differently, to step fully into our role as the patient advocate? Although we can’t divulge specific prognosis, we can discuss the limitations of technology. We can sit with families and discuss the reality of the care provided, and we can encourage them to have those conversations with the doctors: “What is the plan of care, what is the likely outcome, is the technology use just prolonging life without hope of recovery, is the technology use painful or likely to cause PTSD, what will life be like if my loved one does survive, are they suffering from the use of this technology, and what about quality of life now and into the future?”.

Why can’t we just include a list like this as a guide for doctors and nurses in facilitating their communication process, to really strive for educating families, patients, and decision makers around end of life care and futility? Why do we assume that folks really know what it means to “do everything”? We can become more comfortable with the types of conversations families need to have as they approach end of life, particularly if we spend the time to be reflective about our own future death experience and the deaths we have witnessed both professionally and personally. We can think about how different death seems when it is our loved ones facing this transition, and how we perhaps at times distance ourselves from the death of our patients. We can consider how in the last 100-150 years death in America has been removed from the public view, from the home and places of comfort, from the natural progression of life, and consider how death has become institutionalized in our hospitals. We can consider the healthcare costs around end of life care and how that impacts available resources and compounds the amount of money we continue to spend on healthcare. We can think about the nurse’s role around supporting healing at end of life, and what we want that to look like for our profession and those we serve. We can look more closely at our own end of life fears and concerns that make it challenging to care for those hospitalized at end of life.

I am currently teaching a thanatology (study of death and dying) course for nurses that I designed in way to support students to go deeply in their reflective process around death and dying, to explore the holistic needs of the dying, and to delve into the body of evidence around the science and politics of death and dying. While the course is challenging for students on many levels, it is also transforming their nursing practice, touching them deeply on a personal level, and helping them to advocate for others at end of life. I remain hopeful that someday every healthcare provider from MD to RN to Social Worker will have the opportunity to take a thanatology course like this and that out culture will eventually strive to start death education at earlier stages in life, moving toward acceptance that this life is impermanent, and that it is perfectly okay, natural, and normal to die; that one can indeed refuse treatments and technology regardless of age; that living well leads to a positive death experience. There is a new movie available that aligns with this purpose, called Death Makes Life Possible. I highly suggest using this movie as a tool to support discussions around end of life and open up to the possibilities of “transforming fear into inspiration”: http://deathmakeslifepossible.com

Language and Nursing Care

February 23, 2015January 4, 2017 / Jane K. Dickinson / 3 Comments

In 1993, I gave an inservice for nurses on a School-Age Pediatrics Unit. The purpose of my talk was to discuss the importance of putting patients first by avoiding calling them by their diagnoses. We discussed how “diabetic” and “asthmatic” and “leukemic” and “sickler” are labels, and that there is so much more to each child than a disease or medical condition. I was saddened last year when I came across my notes from this talk and realized that things haven’t changed enough. We have not eliminated the words in health care that can hurt people, and maybe even lead to negative health outcomes.

I am a nurse and certified diabetes educator. I have been working with people who have diabetes for 20 years. I’ve lived with diabetes myself for almost 40 years, which is certainly one of the reasons I take language seriously – I know how it makes me feel. I remember my pediatric nursing courses, where we learned to avoid words that were potentially frightening to children, such as “stretcher” and “shot.” Instead we were taught to use “gurney” and “injection.” I also remember a friend who was infuriated when the family physician called his baby “failure to thrive.” “No one is going to call my son a failure,” he fumed, not understanding what the term meant.

In diabetes care there are many words that imply judgment, shame and blame. Words such as “compliance,” “control,” “test,” “good,” and “bad.” And the list goes on – I have heard people with diabetes referred to as “recalcitrant,” “non-compliant,” and even “neurotic.” Nurses discuss patients through both speaking and writing. They sometimes use these words directly with patients, and often with each other. I believe that people with diabetes can sense when a health care professional deems them “non-compliant” or “poorly controlled,” even if they refrain from saying those words to their faces.

Where do those words come from? Why would people who choose a helping, serving career such as nursing, use words that could hurt people? It started with the acute care model, on which our health care system was founded. People came to health care professionals for help and were told what to do to “get better.” Taking medication for an infection, or changing a bandage, is very different from managing the daily tasks of a chronic disease. Since health care professionals don’t go home with their patients and help them manage their disease day in and day out, it truly is self-care or self-management. And it’s hard to deny that our health belongs to us. Therefore, words like “compliance” and “adherence” don’t belong in chronic care. Those words mean doing what someone else wants. People with diabetes make choices every day, and those choices determine how they take care of themselves, how they feel, and their health outcomes.

Another judgmental word is “control.” “Glycemic control” is so ingrained in our diabetes terminology that very likely most people don’t realize how often they say it and read it. But how much control does the person with diabetes actually have? Despite modern advances in technology and medications, it is not physically possible to keep blood glucose levels in the normal range all the time for those with diabetes. With much effort it is possible to manage diabetes, but perfection cannot be achieved. Using words like “control” makes it appear that control is possible and those with diabetes are not doing a good enough job.

Diabetes is a demanding disease with an emotional toll. Many, if not most people with diabetes experience some level of diabetes distress due to the stresses of diabetes. These stresses include the daily tasks of poking fingers, taking medications, scheduling and attending health care visits, and thinking about every morsel of food they eat. Add to that the constant questions and concerns from family and friends and society in general. Having to endure judgmental words from health care professionals on top of all that could really be the last straw. What if our words lead to further burnout or discouragement? Better yet, what if changing our words could empower people with diabetes to take better care of themselves?

Nursing is known as the caring profession because we truly care about people and their health. It’s time to match our words with what we do and what we stand for. Becoming aware of the words we use is the first step. Let’s really pay attention to the words we speak, read and hear in practice and in everyday life, and think about how they could be affecting people’s health. Stay tuned for a future blog post with ideas for words that empower people. And please feel free to add your own experiences with language in nursing care.