Misuse of Resources

I was always told I could do anything I dreamed. I tested out as a gifted student at an early age and have generally kept the company of "brainy" students my entire life. Many of my classmates and friends have already moved on to graduate study in their various fields, some even to medical school or law school. I am somewhat behind them, and will be completing my undergraduate degree after 11 semesters of study instead of the typical 8. (This is due to a combination nontransferable credits and some initial meandering through majors). Yet I am anticipating my graduation next August with great enthusiasm. I feel like becoming a nurse will be a real accomplishment. Though I'm still somewhat surprised to realize it, it is one of my dreams.

I often speak passionately to others about my calling. But this weekend, while I was visiting extended family and friends, I was somewhat deflated by their questions about my career. "Why aren't you going to medical school?" they'd ask.

I made a bunch of standard arguments, mostly centered around the saying "Doctors cure but nurses care". I explained that my desire is to work with people holistically and individually. I want to be present. And I am far more interested in the human elements of health care than the scientific ones. While doctors can do those things, nursing just feels like the best fit.

But none of these arguments seemed to phase them. They couldn't grasp why I'd become a nurse instead of a doctor when I was obviously bright enough to be the latter. They cited a myriad of reasons it would be better for me--most of which boiled down to a supposedly "superior lifestyle". But the one thing that really stuck with me was the phrase "Just wait, you will always be subject to people who are less than you."

I can't help but be upset by the entire perspective. It feels wrong on so many levels.

For one, I don't think a "smart person" going into nursing should be seen as a waste! If I succeed--and I plan to--it will only do credit to the profession, not discredit me. For another, I don't think money is a good reason to choose any career. And perhaps I am naive, but I haven't exactly found nurses to be totally subject to doctors. Nurses seek to be collaborators in patient care; this is the meaning of professionalism. True, some physicians still try to walk all over supportive staff. But people who work in hospitals know it's far less challenging to work with doctors than it is to work with patients! "Subject to those less than you"? Obviously! (Just not how you'd think!)

It's very discouraging to be told that you are, in essence, misapplying your potential. But the thing I think others are overlooking is the fact that my gifts aren't limited to the deduction logical puzzles or the intuitive grasp of certain subjects. So what if I took a test when I was a child that indicated I had some above-average abilities? I have developed others as an adult that are far more important to a meaningful life. They're the more immeasurable qualities of the heart... they compel me to extend my hand to strangers and to listen with compassion. I may not always succeed, but I am a person who is not only able, but willing!

Surely that means more than the money I could have made or the power I could have held. It's not a lack of ambition that set me on this path. It's because I feel like if I place more value on relationships than the other factors, I can't really go wrong. I will have enough money and responsibility. But I will have an abundance of friendship and respect.

Again, it is totally possible for doctors to be and do all the things I describe in addition to their regular jobs. But for nurses, that thing is their job. I watch them while I work. I see what each professional does. And I don't regret my choice, not even a little. Because I know who and what I am.

Resarch Study and Commentary by Dana Rutledge, Phd, RN, Nursing Research Facilitator

RESEARCH STUDY AND COMMENTARY

Schulman-Green, D. et al. (2005). Unlicensed staff members’ experiences with patients’ pain on an inpatient oncology unit. Implications for redesigning the care delivery system. Cancer Nursing, 28, 340-347. Staff at SJO/CHOC can access the full text of this article through the library's web site.

Authors’ Abstract

Although unlicensed staff have routine contact with patients in pain, little research relates to their role with these patients. The purpose of this study was to describe the experiences of unlicensed inpatient hospital staff caring for cancer patients in pain. We sought to understand pain identification and communication practices, describe common practice sitaut9on, and identify training needs. We conducted 4 focus groups with unit secretaries, nurses’ aides, and housekeepers (n = 24) on 2 inpatient oncology units at an urban, northeastern teaching hospital. Group processes were tape-recorded, transcribed, and analyzed using Atlas/ti software and content analysis. Analysis generated 5 issues related to pain in the daily practice of unlicensed staff: perceived function with pain, building relationship with patients, interpreting patients’ pain, system issues, and job challenges and coping strategies. Unlicensed staff reported performing important functions related to pain, including alerting nursing staff to patients’ pain, and providing psychosocial support. Participants shared difficulties of working with patients in pain an expressed interest in education on pain identification and course of illness. Findings provide insight into the role of unlicensed staff, and have implications for the educational preparation of this group as well as the nature of their participation in the care delivery system.

Commentary by Dana Rutledge, PhD, RN, Nursing Research Facilitator

In this qualitative study, researchers described results of focus groups of unlicensed hospital staff who were asked about experiences with patient and pain. Nurses might be surprised at some of the important ways these staff perceive that they impact pain and its management. Patient care assistants (14, the largest group of staff) noted that they were assessing pain using the 0 – 10 score at the time they did vital signs. They reported having difficulty identifying the nature of pain when patients found the 0-10 scale confusing or difficult to respond to. Is this a problem that could occur at St. Joseph?

Those interviewed mentioned their roles in assisting in patient comfort by giving emotional and physical care. Some use nonpharmacologic pain management techniques such as distraction or listening. These staff members consider comfort care important to their roles. Most unlicensed staff reported communicating patient pain to nursing staff, and consider this one of their most important roles.

As with nurses, unlicensed staff identified challenges to dealing with patients’ pain. One was their overall heavy workloads, which interfered when they wanted to spend time with patients in pain. They emphasized the importance of teamwork, individualizing care, and empathy in caring for their patients.

In the discussion of their results, Schulman-Green and colleagues suggest that care redesign that enhances PCA-nurse relationships, expands training for unlicensed staff, and debriefing at intervals would improve pain management for patients in pain. What do you think?

BP?

Oh ya, and trying to get an actual accurate reading of a blood pressure on a baby is damn near impossible! (3 of us tried, 2 of "us" being actual RN) and I got it first, after 3 tries! oye...

NPA

OK, cool clinical for me, YAY!
I had a 20 day old baby boy, in for rule out sepsis and possible meningitis. The MD asked for us to do an NPA (naso-pharyngeal aspiration) and my co-assigned RN let me do it! I was with my clinical instructor and 2 classmates and man was I nervous! BUT did not let it show... as both parents were there. It was the first time I was doing this procedure on a live person, let alone a baby!
Managed to do it without incident and we got the sample and sent it to the lab. No idea what the results are though as we had to leave.. hope the little guy is ok.
Can't wait to do more skills like that.



"Nasopharyngeal Aspiration for Respiratory Virus or Bacterial Testing

Requires a suction mechanism (syringe, vacuum pump or wall suction), a specimen trap and catheter.

Insert catheter nasally into posterior nasopharynx.
Apply suction as catheter is slowly withdrawn. Do not leave sample in tubing.
If sample has been aspirated into a syringe seal the end of the aspiration tube and send specimen in syringe
or wash aspirate through tubing or trap with:
• 3mL of virus transport medium if for viral diagnosis only
• 3mL of sterile saline for microbiology culture/sensitivities and or viruses
Place sample in transport medium into sterile transport vial.
Ensure that the top of the vial is screwed on securely.
Label with patient name, date of birth, sample type and date of collection."

who me? ...Uncoordinated?

OK, went to Starbucks and bought a Grande Pepermint Mocha, then proceeded to walk home with it... ended up with some on my pants!
Damn I can't walk and drink coffee at the same time.. wonder if I can still walk and chew gum at the same time!

St. Joseph Hospital PACU Nurses Win Poster Presentation Award

Tracy Dickman, RN, BSN, Clinical Nurse II, Pavilion PACU, Darlene Soriano, BS, MHA, Surgery Support Specialist, Pavilion, OR, and Dana Rutledge, RN, PhD, Nursing Research Facilitator, won first prize among 14 other presentations for a nursing research poster at the recent Joint Southern California STTI Chapters Odyssey 2006 Conference.

This prestigious honor was bestowed along with a plaque at the Ontario conference October 26-27. The poster presentation described an action research project carried out in the Pavilion PACU.

During Fall 2005, Alicia Leal, BSN, RN, CPAN and other PACU staff initially designed the research study that examined patient flow within the Surgery Center. Tracy analyzed the statistical data collected and noticed a potential clinical problem. Tracy then met with Kathy Dureault, RN, MSN, Clinical Educator. Many patients were arriving unprepared to ambulatory surgery (e.g., did not have transportation home or a responsible adult to be with them upon discharge, etc.). Kathy connected Tracy with Dr. Rutledge, who discussed how to evaluate the nature and intensity of the problem using survey methodology.

PACU nurses implemented an action research project. They found that in over 600 patients admitted for surgery, 75% had received the Personal Recovery Plan Pamphlet (PRPP) developed by SJO nurses and disseminated through surgeon’s offices. In all patients who received it, the Plan was perceived as helpful. Of the patients, 78% received a preoperative call from SJO staff. Despite not all patients receiving the pamphlet or call, 99% of patients thought that their preparation for surgery was adequate.

During fall 2006, Darlene called surgeon’s offices, making sure staff understood how the PRP was to be used. She updated and converted them into electronic files available of the English, Vietnamese, and Spanish versions to enable staff to keep copies readily available in offices. The PRP is also now available on the SJO Intranet/website at http://www.sjo.org/ under the Patients and Families link. You can also view the Personal Recovery Plan Pamphlet here. Between Thanksgiving and Christmas, Tracy and PACU nurses will be surveying patients again to determine proportions of patients who have been adequately prepared for their surgeries. They hope to see a change.

Implementing a Sedation Protocol for Ventilated Patients

One of the presentations at St. Joseph Hospital's recent Grand Rounds on Evidence Based Practice and Nursing Research was "Implementing a Sedation Protocol for Ventilated Patients" by Victoria Randazzo, RN, BSN, CCRN, Clinical Nurse IV, Intensive Care.

Victoria discussed the practice change in progress in the Intensive Care Unit. You can review her complete PowerPoint here.

Group Visits for Diabetes Management

One of the presentations at St. Joseph Hospital's (Orange, California) recent Grand Rounds on Evidence Based Practice and Nursing Research was "Group visits for Diabetes Management: an evidence based approach to chronic disease management" by Teresa Ulrich, RN, FNP, Family Nurse Practitioner, La Amistad Health Center.

Teresa educated the audience on “Shared Medical Appointments” and specifically a group at La Amistad focused on diabetes management that started November 2005. An added bonus to her group was the inclusion of family members who could also reinforce the education presented at these group visits. You can view her PowerPoint here.

Five-Minute e-mail Nursing Journal Club

One of the presentations at St. Joseph Hospital's (Orange, California) recent Grand Rounds on Evidence Based Practice and Nursing Research was "Five-Minute e-mail Nursing Journal Club" by Judy Rousch, RN, Clinical II, Critical Care. Judy presented a project she began in 2003. Inspired by the public library’s on-line book club, she began sending small excerpts from scholarly nursing journals to a selected nursing e-mail readership. She highlighted how she dealt with format, copyright protection, etc. You can view her complete PowerPoint here

SJH Action Research: Decreasing Incidence of Bleeding and Hematoma Formation in New Fistulas

Action Research Summary Outline

Investigators:
Carmeleene Baguio MSN, RN Vascular Access Coordinator Renal Center, Dr. Amer Jabara, Renal Center Medical Director, Dialysis Staff in the Outpatient chronic hemodialysis unit

Problem identified:
Bleeding and subsequent hematoma on new fistulas when initially used for hemodialysis. When this occurs the fistula is allowed to rest for 2 weeks. This allows the hematoma and bruising to resolve. Sometimes it takes longer than 2 weeks or the hematoma needs surgical evacuation. This delays the use of the fistula and increases the risk of the fistula failure.

Purpose of the project:
To investigate the factors or reasons that cause excessive bleeding when new fistulas are initially used.

Evidence/Research:
The arteriovenous fistula (AVF) is the “gold standard) for vascular access. Fistulas have the longest longevity (75% working at 3 years, least likely to be infected (35x less than central venous catheters, 10x less than grafts), and lowest mortality (3x less than central venous catheters).

The Kidney Disease Outcomes Quality Initiative (National Kidney foundation, 2001) and the American Nurses Nephrology Association (ANNA) Standards and Guidelines of Clinical Practice for Nephrology Nursing recommend the AVF as the first choice of access.
The Fistula First Initiative recommends that 66% of patients on chronic hemodialysis use fistula as their primary access by year 2009.
Evidence shows that skill is required in creating and cannulating new fistulas.
28-53% of fistulas never mature to support dialysis ( Beathard, 2006 American Society of Nephrology)

According to Brouwer, 2003 a new fistula must be treated with great care to prevent damage. The goal is to help the access to mature into a long-term lifeline for the patient. She has recommended some guidelines in the care of this new fistula.
Several factors impact effectiveness of fistula placement and function. A multidisciplinary approach to evaluating and managing fistula maturation increases the chance of success.

Action Plan:
I discussed this problem with St. Joseph Hospital research council chair, Dana Rutledge, Dr. Jabara, Medical director of the Renal Center, the experienced dialysis nurses and technicians to get input on how what they thought was causing this problem. Based on current guidelines in the successful use of new fistulas a data collection tool was created to collect retrospective and prospective data on patients with new fistulas. This information consisted of possible factors that could affect bleeding and subsequent hematoma when new fistulas are initially used.
Retrospective and prospective data was collected on patients that had new fistulas that were being used for the first time. I informed the staff of what the plan was to address this problem.
During the data prospective data collection the staff was aware to check patient’s heparin dose based on the ACT’s, coumadin and other oral blood thinners that patient might be taking, patient education on holding needle sites post dialysis. As Vascular Access coordinator, I collected the data and facilitated patient referral to Interventional Radiology or vascular surgeon. I also did staff and patient education in the clinical area while data was being collected.

Outcomes:
Data was collected on six retrospective and six prospective patients that had new fistulas. Data included: Age of fistula when initially used, needle size used, heparinization during dialysis, other anticoagulants that patient was on, activated clotting times (ACTs), other bleeding issues, patient medical history associated with hematologic disorders, prescribed and/or complementary or alternative medications used by the patient and physical examination of the fistula.
Chart review was done using the data collection tool. Retrospective data showed that four of these patient’s ACTs were prolonged. Two were on coumadin, and two patients had narrowing of the fistula. Heparin dose was adjusted according to the ACT result.
For the prospective patients, heparin dose was evaluated and adjusted based on the ACT’s. This was done prior to using the fistula for the first time. Four of the patients did not have any bruising after the fistula was initially used. Two had minor bruising. This was related to needle manipulation since the fistula was not mature to support dialysis.
How is this significant?

There was a significant decrease in the incidence of bleeding after new fistulas were used for the first time.

Recommendations:
There will be an increase of new fistulas as a result of the Fistula First Initiative.
Systematic assessment of the new fistula before first use is imperative. Using the data collection tool created for this research will be useful in assessment of new fistula.
Patient and staff education on care of fistula and graft infiltrations to promote longevity in the use of these accesses.

Knowledge and Attitudes of SJH Nurses on Pain and Management

On Friday, November 3, 2006, St. Joseph Hospital (SJH), Orange California held the second annual session of Nursing Grand Rounds focused on Evidence Based Practice and Nursing Research. The four hour presentation was developed by Dana Rutledge, RN, PhD, Nursing Research Facilitator and Sharon Kleinheinz, RN, MS, Clinical Educator. One of the presentations was by Maureen Mikuleky RN, BA, MA, Director of Cancer Services and dealt with the findings of a recent questionaire Knowledge and Attitudes of SJH Nurses on Pain Management. You can view the PowerPoint presentation here.

Travel Nurse: Checklist (Housing Stipend)

Another name for this post might be "Things I wish I'd known before signing with my first travel nurse agency." I have compiled the following checklist of housing related questions I now ask prior to taking any travel nursing assignment. Get stuck living in an apartment in Chicago next to a train station located 45 minutes from your work facility and you will quickly learn the value of the questions contained in the checklist. Trust me, it's no picnic. On the other hand, the "resort" condo in West Palm with fenced in pool, hot tub and spa was right up my alley.

HOUSING
Ask the agency:
1) What kind of housing is being offered, private or shared?
2) If shared, can I request a nonsmoking roommate or a roommate that works the same shift as I do?
3) Where is the housing located and when can I move in?
4) Can I get a housing stipend if I live in a home I have purchased in my new assignment area, live out of town with friends or relatives, or rent a home on my own while on assignment?
5) If the travel agency offers a stipend to pay for utilities, when is it paid and is it taxed?
6) Does the assignment I'm considering offer free private housing?
7) Can I take my spouse, significant other, children or pets without any additional charges?
8) Is the house or apartment furnished?

Finally, from all the research I've done, the most important bit of advice I can give is that everything should be included in a written contract. What sounds too good to be true probably is, and the only way for us to be sure we will get all the things we've been told we will get, is to have it put in writing. We should ask our recruiter and the facility to put down on paper the things that are most important to us (if they haven't already). There are lots of agencies and millions of facilities out there, we should be a ble to get what we are looking for and we shouldn't have to settle for less.

Travel Nurse: Checklist (Work Facility)

This is my second post with checklist questions you will need to ask about your travel nurse assignment before you sign on the dotted line. The following questions are what all travel nurses should ask their travel nurse agency to avoid any unpleasant hidden surprises. Check out my travel nurse housing stipend checklist and my travel nurse salary, insurance and benefits checklist.

YOUR FUTURE WORK FACILITY
Ask the agency:
1) Has the facility used travel nurses before?
2) What is the nurse/patient ratio per shift?
3) Will there be unlicensed staff or other ancillary staff in the unit?
4) What type of scheduling is done (weekly, monthly, quarterly)?
5) Will I work in 4, 8, or 12 your shifts?
6) What are the facility's orientation procedures?
7) Are study guides provided and testing required?
8) Are there any licensure issues?
9) What type of charting system is used?
10)Do travelers float first and, if so, to what areas?
11) What are the expectations regarding being "on call"?
12) Will I be able to or required to work overtime?
13) Who do I talk to about time off, and what are the requirements for having it granted?
14) Who do I contact (the facility, my recruiter, my employer, other) if I have a problem or an important issue to discuss?
15) Is there an agency representative available 24 hours a day, 7 days a week?
16) What if my recruiter is unavailable?