by Paula Manuel Staff Nurse Interest Group

The past couple of weeks my management practice has involved crucial discussions with families about their loved ones.  For one patient it was his family’s frustration of emergency services more about chaos than serving an elderly, sick, and vulnerable patient.  Transferred to the inpatient unit only to be treated with indifference by some and the prolonged wait for a call bell to be answered, confusion that 24 hour care was needed to keep him safe but here he was in a room by himself….The mixed messages from the health team “you need to stay”  “no you need to leave now there’s no room for all of you” “I don’t have any information to give you, besides privacy laws forbid me and I have only had the patient four hours, and the doctor is the one to provide the test results and what will be the plan of care”.

The second family their loved one had been in and out of various hospitals, his condition a mixture of co-morbidities that included metastases, renal failure, cardiac issues, profound deconditoning, and the family were absolutely dead set against palliation.  Their perspective he just needed more nutrition, a concrete plan to get him moving, and to get him home.  Suffice to say it took a number of discussions, a discharge that ended in a re-admit in less than 24 hours, the persistence to explore and build trust and display empathy, coach the staff on viewing the family not as difficult but distressed and how could we de-stress them.  To gently move a wife from denying her spouse was dying, “don’t talk like that in front of my husband….it no good for him to hear such talk” “the team say there’s no use, it’s hopeless, how do they know…he is a fighter he has survived more predictions from doctors  ‘he’s dying’, than a cat” “we do not want the doctors to actively end his life….so palliative care is a way of supporting him not pushing for death” 

A major focus in many organizations is to design and deliver their services to increase customer satisfaction and in the domain of health care the patient/client experience. Patients within the last decade or so have been told they are major stakeholders in the health care system.  Their health status reflects where they live, what choices they have made, we can assess how determinants of health influence their lives related to income, gender, culture, language, education status, from demographics to death rates we can amass a mountain of data.

Concurrently we have seen the emergence of the consumer movement, the shift from doing care to them to delivering care with them.  You see this in the language of forming partnerships, acknowledging and encouraging empowerment because we need to remember it is their health condition.  As nurses we need to be mindful of their intrinsic strength to manage their ailment, to be aware of the potential of power imbalances, not to be judgmental about choices made, or to be frustrated when they share their expert opinions and perspectives on their care needs, priorities, and expectations.  Many of us will recognize the challenges when family or patients share their perspectives, question the modalities of care and consult Dr. Google via the internet then quiz you on why X is not being done.

Let’s consider how we used to measure a patient’s success we used rates of compliance and judged their success on meeting criteria usually set by us “the professionals”, for the patient it required them to be passive; following instructions contained within treatment protocols, and if a patient challenged the status quo of their relationship with the professionals, acted in a “rebellious” fashion, were incompetent, and or a nuisance they would be deemed non-compliant aka not getting with the program.

Adherence at least acknowledges that a patient has a more active role than simply follow directions or a directive; collaboration takes place in the context of unconditional support to motivate a patient; to follow the advice provided, as well patient acceptance is connected to the trust they have in their team, supporting their ability to self-regulate an illness/condition or treatments.

Concordance is an active process for both the professional and the patient as it entails building a relationship, being mindful that in our interactions we need to consider the two sets of health beliefs involved. In this way a shared decision can be made that fully considers the patient and the health care team’s beliefs and preferences and to recognize that the patient’s views are paramount = health beliefs.  Mutually the care providers and the patients will share their perspectives, respect for the patient’s point of view is vital to forming a therapeutic alliance. This alliance though reciprocal requires us “the professionals” to remember the most important determinations are those made by the patient.  This for me captures how we provide nursing with the patient not to the patient.

Health care agencies, organizations, clinics et al measure a number of outcomes and patient experience is a significant factor to confirm the staff are delivering on the why and how of quality patient centred care. The patient’s (or family member) perception is the only input into patient experience, as health care professionals we provide our knowledge, skills, and attitudes to provide patient centred care that includes respect and dignity, information sharing, participation, and collaboration.  A patient could be anywhere on the continuum of engaged to disconnected.  The patient who is emotionally involved in their health and well being will be more likely to share key aspects of their condition, participate in a plan of action, adhere to the plan, actively engage in using communication technologies i.e. email, Telehomecare, Skype, interact with other patients and the ultimate engagement have a positive influence on their own health status.

The vignettes shared from my practice illustrate the challenges the health care team can face when some core competencies are not provided.  Listening, empathy, share information and understand when privacy standards apply, build trust, share knowledge, be hopeful and realistic all are in the domains of nursing practice and yes they take practice to master them.  One of the patients is close to being discharged back to his long term care facility, the other patient passed quickly through a respiratory phase that ended his life.  His wife was called and as gently as can be done over the phone told of his breathing problem, he died before she arrived to the bedside and the nurses assured her he was not alone, he did not suffer, he went to sleep and they maintained their quiet vigil of being a presence and providing privacy.

Namaste

 

On any given day or night the following scenario may be seen, two nurses speaking to one another perhaps during shift change, or a call for help with an assignment.  One says “I need help with the patient in Room XXX”, the other nurse responds “what’s wrong with you, you have the lightest assignment and you can’t cope with it”

In the nursing station a nurse asks the responsible physician “why are we adding to this patient’s pain and suffering?  It does not seem to be the right thing…..”  The doctor responds “It’s what the family wants–they want everything done and now everything is about patient experience scores”

These two vignettes though limited in detail provide a snapshot of conversations that occur  for any number of nurses; conflict about what is valued, how one can be perceived, and how to navigate an ethical dilemma when there are competing priorities.  Nursing is a practice discipline and the ethical frameworks we utilize have to consider our perspectives as an individual, within an organization, and the society we live in.  The real life experience of professional values is framed within our education, affiliation with our regulatory bodies, self-reflection about our life experiences related to gender, culture, family, community, and religion to name a few.

One of my courses generated an opportunity to consider in more depth the professional values of nursing  (Shaw and Degazon, 2008) highlighted how nursing programs would need to be more diverse i.e. cultural, racial, age, gender etc. a significant driver for this change was the retiring workforce and high nursing turnover (US based). Their view was that a common nursing ideology and mission were needed so that bridges will be created among nurses of varied backgrounds. The process would involve modifying old personal and professional values and internalizing new ones. The core professional nursing values, not dissimilar from Canada, were adopted by the American Association of Colleges of Nursing in 1998. The values adopted were:

  • altruism,
  • autonomy,
  • human dignity,
  • integrity,
  • social justice.

The article described how nursing students were initially  consumers as they internalized the professional values and the challenges they had as graduates as they transitioned into professional settings, and some employers did not engage in the process of socializing new nurses. The level of support that would include casual and/or part time status versus full time permanent positions.

Altruism is a traditional value considered a primary motivation for entering the nursing profession, the words devotion, caring for others, selflessness are some of the characteristics; but many contemporary students are focused on financial incentives, career mobility and stability. Shaw and Degazon pointed out that altruism must be taught, learned, and integrated into practice, thereby a common understanding will emerge of the meaning and satisfaction of helping others.

Autonomy includes self-determination and being self-directed, and how nurses need to support patients in their decision-making especially when different from their own values. The skill of collaboration is needed with patients, families, and colleagues regarding sensitive topics i.e. end of life, and having awareness of the dilemmas encountered in professional practice when conflicting views and value-laden issues arise. Subjectively a nurse needs to know their own cultural values and consider the elements of truth telling, self-determination and individual options.

Human Dignity this value is the basis of respectful treatment to patients, families, and colleagues and interactions will be more therapeutic, productive, and professional. The caution by the authors was to be aware of the role assumptions may play in personal and professional endeavours, also known as biases, whereby you may not interact with an individual but instead use your assumptions about that individual.

Integrity is linked to the Code of Ethics and the principles of non-maleficence, beneficence, fidelity, veracity, and social justice. The focus on this value was how contemporary society has many examples of ethical standards and integrity lapses by government officials i.e. NY governor and call girls, business executives i.e. Enron, and clergy i.e. priests. The need for integrity by nurses in practice is how we merit public trust. Shaw and Degazon profiled how a number of immigrants admitted to bending the rules to cope with a complex immigration process and making things happen was considered a higher purpose. As nurses we can acknowledge a client/patient’s perspective, but as nurses we understand that knowledge and application of professional standards translates into accountability.

Social Justice is “the moral and ethical imperative to respect the basic rights of others” (Shaw & Degazon, 2008, p.49) and how collective action enhances the power of individuals to create change for individuals, families and communities. Within this value the phrase “Choose a job you love, and you will never have to work a day in your life.” by Confucius is a nurse’s ability to recognize the impact of social policy, and to know about the rich legacy nurses have in activism to improve social and health opportunities and outcomes i.e. SARS, closing coal plants, equal rights for disabled persons, sexual orientation, bullying.

In terms of consumers Bowman (1997) outlined how bioethics had evolved from Western moral philosophy and Western biomedical perspectives. Our patients and families may have very different perceptions, experiences, and explanations of illness as their world-view could be Western or non-Western and this will affect cultural context, how illness is explained, and locus of control. So autonomy maybe a value for some of the consumers but others will value interdependence. Bowman also highlighted how the Western perspective can be an either/or and a non-Western perspective maybe grounded in a dynamic equilibrium i.e. yin and yang.

Truth-telling has a high value in the Western view seen as the patient’s “right to know”, and for the non-Western view it can range from believing the patient should not be told, to the family are given the information and they’re expected to inform and support the patient. Bowman illustrated how important it was to explore the “consumer’s” cultural perspective, as professionals it would be safe to say there is value in clarifying their world view and we have to be open and receptive.

Our professional values likely complement the ones held by our public. So to answer the question similar or different values for nurses from the public; I say on most values we are on the same page and the differences mean we have subjects to explore and to gain insight i.e. to the diversity of world views. Our health care services need to reflect cultural pluralism and here’s the challenge… how to effectively do that in the climate of limited resources, time pressure, and the high value placed on efficiency. Human beings are not tidy boxes, indeed we are not working on widgets but complex beings.  Patient experience metrics and values stay tuned.  Namaste

Sources: Shaw, H.K., & Degazon, C. (2008). Integrating core professional values of nursing: A profession, not just a career. Journal of Cultural Diversity, (15)1, 44-50

Bowman, K. (1997). BIOETHICS AND CULTURAL PLURALISM. Humane Health Care International. Volume 13 (2), 31-34

Dear Nephew

My nephew also known as the clone of my brother is about to start his nursing program in a couple of weeks.  I have invited him to read my blog, not sure if that has happened–I am encouraged that he has obviously been thinking about the program, as evidenced by comments on future pathways around specialty and nurse practitioner and I like to believe I have influenced him somewhere along the way (well perhaps a number of times).

My nephew is of course in my eyes a delightful young man (his brother is my other delight) and I am impressed by his approach to research the programs, recognized the importance of academic marks from high school, and he adapted and showed flexibility to achieve his objective to be admitted into a nursing school.  I also commend his parents who have supported his efforts and this weekend like many other parents will be transporting their first son to start his new chapter in life–adulthood.  The kitchen essentials, laptop computer, and other necessary materials/equipment are packed to go, along with a Littmann Cardiac II stethoscope (from Auntie Paula) and a copy of Nightingale’s Notes on Nursing.

It is remarkable to reflect on how different his nursing program will be from my own 20th century experience, as his school has advanced simlabs with state of the art technology to practice the skills needed.  Travelling back in time I recall one of my first clinical experiences to make the bed and communicate with the patient.  The communication segment of the clinical revealed an array of core competencies to listen, to observe, to consider/reflect, to analyze, to determine needs, to forge the relationship that would be therapeutic. The process of becoming a nurse was to recognize that no task is purely technical that learning to be a nurse was blending knowledge, skills, attitude, and cultivating the emotional intelligence domains of awareness, empathy, social skills, and managing one’s own moods and emotions by analyzing not judging to think before we act.

On the off chance my nephew and/or a new nursing student reaches this point consider these points:

  • Regularly check your own vital signs, how do you feel, how is your level of joy, wonder, creativity, and you will need to learn how to reflect on your experiences
  • Learn the science and art of empathy, heed the heart and acknowledge your emotions while in practice and when the clinical period is completed for the day–feel the emotions you will be sad, angry, frustrated, question how futility can be set aside when a real dialogue is needed and you will be exhilarated, inspired, and awed
  • Always take care of yourself first; body, mind and soul–ensure you have what you need and take time to determine what do you need?
  • You are going to transform many lives, sometimes making a difference with a smile, a gentle touch on a shoulder, recognizing a sentinel moment and literally save someone’s life, answering a call bell with a attitude of can do, kindness, and providing quality moments over and over
  • Be inquisitive, be honest, practice excellence, be assertive and zero tolerance for abuse of any kind, don’t worry none of us know everything we’re always learning
  • Have fun, you are about to enter one of the most respected and honourable of professions, you will also bear witness to people who will engage in some dumb acts, you will encounter noble people and downright smucks.  Fortunately most people are grateful you’re willing to help them with some of the most intimate of care tasks.

From your wise and experienced auntie Namaste, I am so proud of you and all the new nurses starting out on their magnificent journey to be nurses.

Summer Days & Thoughts

In my locale of the world the temperature has been hot though it does not compare to what some in the world have faced–extreme weather, terrorism, strife and war, famine, fire and or flood.  A bright spot is the Olympics are underway and the athleticism is always amazing, how a human body can be trained to perform at such a razor’s edge; that a blink can be the difference between winning or losing.

The Olympics celebrate speed, daring, dedication, effort, and show us the difference between champion and participant is very narrow.  Competition is an interesting sidebar as the practice of being a nurse has my leisure time more focused on enjoying the experience not driven to win.  Opportunities to compete have revealed that I can focus, though likely a skill cultivated more in the myriad of details of critical care; and the skills of sportsmanship and being graceful in defeat fit into my toolkit of leadership behaviour–sure I can envision pretty much anything, having the certainty indeed the unwavering drive to capture victory is not the primary focus.

Okay some of you will say bowling and golf are not pure sports–daresay walk 18 holes on a day with a high humidex and you will know your body worked out.  Well it is for me and though some say the white ball spoils a good walk–there are the opportunities to revisit childhood those summer days hot and slow moving, lasted forever and play time was a primary pursuit.  Now it’s about carving a few hours here and there, alas adulthood can be a limitation.

My “sports” are both social in nature; in addition to being outside for a time one can also spend time with friends and share some laughs, that is good personal therapy indeed.  Fortunately I enjoy my status as a casual athlete I don’t earn my living playing golf, I do a fair job striving to be the nurse you would want to work with.  For that dimension my practice bag has knowledge, skills, leadership, political skills, and teammates.  There are even the equivalent of coaches, well senior leadership, and that is a great advantage to know someone is leading the team.  Enjoy what’s left of the summer and may calm conditions be the norm.  Namaste.

As Nursing Week is almost here it’s as good a time as any to reflect on your own state of health, as a nurse you are vulnerable to caring for others and excluding yourself from much needed health management.  The aim of caring for ourselves taking “me time” is not selfish behaviour indeed it is necessary behaviour; it does takes practice to reconnect, focus, organize, energize–well actually just do it.

The to do list to achieve and sustain wellness, and for that matter be the person you would like to work with, live with, play with, love with, can take on overwhelming dimensions. Gaining healthy habits does require clarity, desire to change, and you need margins for lapses because it’s not about attaining perfection.  There are so many avenues to gain information on health whether physical, emotional, financial, spiritual, and it means you also need to be an astute evaluator of information sources, wise who you will listen to, and open to new ideas and yet value common sense.  The desire to change and translating that into action means constructing a plan indeed your very own care plan, and as the nursing process lays out when you have assessed yourself (honesty is a good value to apply to yourself), decided on the priorities, defined the goals, set down the action plan, you    implement and of course evaluate.

What am I talking about?

Well in terms of being resilient what concrete tasks/to dos could be considered and acted on?

Obtain adequate sleep, it is a basic need and the impact of insufficient sleep cascades into any number of negative outcomes–fatigue, cognitive impairment, depression, hypertension, obesity, stroke, cardiovascular disease, the very quality of your life.

  • Here’s a starting point no electronics in the bedroom, only exception a music source but only to play music–when you listen to music it can inspire you, motivate you, in this case we’re seeking calm and relaxation (the lullaby effect).

What attitude are you exhibiting at work or even in your household?

The energy you send out positive or negative is what you will receive back. Consider this

  • Practice compassion for everyone you come in contact with; smile, make eye contact, be wholly present (not thinking of your next task), learn and apply what empathy is about and make it a strength.
  • Don’t judge–clarify with others what their motivations are and/or mindset about about the situation, be careful what stories you create in your mind that prevents you from truly knowing the others’ reality.
  • Seek out learning opportunities, embrace learning opportunities (instead of approaching it like a root canal), be change savvy instead of change resistant.
  • Share your knowledge, appreciate the lessons you have learned, share your wisdom through stories. Celebrate that you have survived through challenges, adversity, and loss in the same way you have had successes, exhilaration, and meaningful moments.  I have celebrated first smiles, first tooth, first walks, graduations and commiserated when divorces, death, and other significant losses were shared.

Life is such a privilege, lifestyle can be altered/influenced by your attitude, through mindfulness and if necessary with the assistance of professionals.  Life is not about having it easy, indeed for many of us having a higher purpose means a life that shows the effects of overcoming whatever life throws us. It could be the traffic woes when we drive to work, it could be crop failure for our family, it could be a raging fire overtaking where we live, it could be a prognosis that may well shorten a life. Write your own mission statement and commit to it, transform your life, connect to passion and if that includes your nursing aspect of your soul–well you are on your way to be the nurse you want to work with.

Namaste

How To Care For Self

This video includes some ideas we discussed and identified as key elements for one’s own health during our Annual Think Tank.  In the last entry of the blog Life of  a Nurse you were able to see how staff nurses are vulnerable to burnout and compassion fatigue.  Managing the factors that result from burnout and mediating the effects of compassion fatigue is not an individual pursuit, indeed to really succeed you really have to build a team of individuals, and access a variety of tools to manage the stressors of working in health care.

Learn about and understand the effects of fatigue and how to mitigate them

Mindfulness and Meditation

The importance Of You Within A Workplace

Complementary and Alternative Therapies & Law of Attraction

Resiliency and Adversity = Resources for Hardiness, empathy and understanding vulnerability.

Namaste

 

 

“Everyone wants to live on top of the mountain, but all the happiness and growth occurs while you’re climbing it.” –Unknown

I have always (well most of the time) practiced self-care in a way that permits me to meet the demands of my chosen profession of nursing.  It is not possible to be an effective nurse if your own physical, emotional, and spiritual needs are in disarray.  Certainly I had episodes of burnout and compassion fatigue and my transformation came about by committing time, resources, and using all my knowledge, skills, and spirituality to nurture me. The ongoing journey has enhance my life and I strive to deliver service excellence without compromising my own well-being.

That said when reviewing info from various sources of note; nurses who are less experienced, exhibit decreased compassion satisfaction (emotionally not present, indeed unhappy) are at risk for burnout. Some individuals who exhibit high levels of caring, paradoxically, are more susceptible to compassion fatigue.  Literature has different criteria for compassion fatigue and burnout but generally the following captures the symptoms:

Cognitive, lowered concentration, apathy, rigidity, disorientation, minimization, preoccupation with trauma

Emotional Powerlessness, anxiety, guilt, anger, numbness, fear, helplessness, sadness, depression, depleted, shock, blunted or enhanced affect.Experiencing troubling dreams similar to a patient’s dream. Suddenly and involuntarily recalling a frightening experience while working with a patient or family

Behavioral, irritable, withdrawn, moody, poor sleep, nightmares, appetite change, hyper-vigilance, isolating

Spiritual, questioning life’s meaning, pervasive hopelessness, loss of purpose, questioning of religious beliefs, loss of faith/skepticism

Somatic, sweating, rapid heartbeat, breathing difficulty, aches and pains, dizziness, impaired immune system, headaches, difficulty falling or staying asleep. (Portnoy, 2011)

Burnout is a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations, an individual can feel disillusioned, negative, and a heightened sense of vulnerability.

Compassion Fatigue is a type of burnout that can emerge suddenly, tends to be more pervasive, and inherently linked to empathy.  It is a natural consequence of stress, that results from caring for and helping traumatized or suffering people.  This condition can be more profound as you can experience a loss of meaning and hope, indeed have reactions associated with Post Traumatic Stress Disorder.

The personal impact can manifest as decreased motivation, apathy, lower morale, increased absenteeism, even deciding to leave the profession of nursing.  The costs are significant and the need for intervention are individually based and at the organization and system level.  Consider this and part 2 will arrive soon….Namaste

“Once you become aware of what stands in your way and become willing to release it, you signal the universe that you are ready to manifest the life you were meant to live.” Chérie Carter-Scott

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