Questions Can Keep Patients Safe

By E’Louise Ondash, RN

Nurses take pride in being right.

We know what we’re doing, we know what’s best for our patients, and we usually don’t like being challenged. So when a patient or a family member asks questions, we may feel as though we are being unjustly interrogated or not doing our best. But when it comes to patient safety, nurses should both welcome and accept questions because we need all the help we can get.

Statistics on hospital errors in this country are staggering. According to the U.S. Department of Health and Human Services:

• There are approximately 400,000 drug-related injuries in hospitals annually.

• An estimatedt 180,000 Medicare beneficiaries die annually from accidents and errors in hospitals.

• Each year, up to 10 percent of all hospitalized patients contract preventable infections while in the hospital, and nearly 100,000 people die from preventable infections.

• An estimated 6,000 “serious errors” occur every month to Medicare beneficiaries. This includes mistakes like operating on the wrong limb, injecting the wrong medication or leaving materials in the body during surgery.

Hospital staffs everywhere are working to reduce these numbers by putting into place protocols and systems that will help decrease errors. One element of this safety movement is learning to listen to patients and their families and encouraging them to ask questions, even if that means we must take extra time to listen or explain.

Nurses should be aware, too, that consumers are being told that they and/or their families must be watchdogs and that asking questions is necessary and wise.

In 2007, the Joint Commission mandated that health care organizations "encourage patients' active involvement in their own care as a patient safety strategy,” and studies have shown that patients who are involved with their care have better outcomes.

So the next time you encounter a patient or family member who expresses doubt or confusion about what you are doing or questions doctors’ orders, thank them, answer their questions and encourage them to continue such inquiries. Their questions might prevent a serious medical error.

If you are a veteran nurse, have you seen over the years a change in patients’ willingness to question their care?

How do you feel when patients or families express misgivings about their care?

Tell us about it.

Symbols of the Healing Arts

By Laura Webb, BSN-RN, MRP

Greek mythology can be confusing. The stories started circulating so long ago,  yet Ancient Latin terminology and Greek mythology continue to influence modern day healthcare. Take for example the symbols of snakes on a rod. One symbolizes the role of the physician, while the other stands for the registered nurse.

The classic symbol for RN is the Caduceus (also known as Hermes’ rod or wand). Hermes’ wand is entwined by two coiled snakes and is topped by a pair of wings. Some people think that the wings represent the caring (angelic) side of nursing. However, according to Greek mythology, Hermes (also known as Mercury), was a magically winged messenger, rumored to have wings on his feet. He also dabbled in alchemy (chemistry, medicine, and metals). So, his wand seems apropos for RNs. I am sure that every nurse has had moments when he or she would be glad to have wings on their feet!

The other famous snake-on-a rod belonged to the Greek mythological god of healing, Asclepius. Unlike Hermes, Asclepius did not have any wings on his rod.

The symbols sometimes get confused, and are used to represent other “healing arts” besides nursing and medicine. But, it is amazing that these symbols have endured for such a long time as signs of healthcare professionals.

Of course, nurses have many other symbols. I have seen the symbolic nursing cap on many patient call buttons. Yet, it has been a long time since the majority of nurses donned caps.

One of the most enduring symbols of nursing is Florence Nightingale’s lamp. Many nursing schools still conduct pinning ceremonies at graduation time, complete with the symbolic lighting of the lamp.

Some nurses adopt patron saints or other symbols. Do you have a favorite nursing symbol or emblem?

Nurses Are a Force for Change

By E’Louise Ondash, RN

When we care for our patients – whether in acute or non-acute care settings – we tend to focus on solutions for immediate problems. They can be serious problems, but at some point, many were not. Often, the health challenges facing our patients today could’ve been prevented, and that’s what the most recent report, issued May 21, from the Centers for Disease Control and Prevention (CDC) tells us.

Americans apparently haven’t learned a thing about making healthy lifestyle choices since the last time the CDC told us that we needed to make changes, the report concludes. We’re doubly guilty this time around because, unlike several decades ago, most of us know what the right choices are.

Here are some of the points included in the latest report from the CDC's National Center for Health Statistics:

• About 1 in 5 Americans still smoke.

• Most Americans still eat too much.

• Most Americans still don’t move enough.

• Binge drinking is on the rise.

The consequences of all of these behaviors are not just felt by the offenders; they are economically catastrophic for our entire country. And at a time when everyone is screaming about the cost of health care, I’m wondering why we hear so little about the financial consequences of smoking, obesity, the lack of exercise and excessive use of alcohol.

The CDC estimates the price tag for smokers’ illnesses is $96 billion annually in direct health care costs, and an additional $97 billion in lost productivity. The direct and indirect costs of obesity and its consequences – type 2 diabetes, heart and vessel disease, hypertension, colon cancer, gallbladder problems, joint problems and postmenopausal breast cancer – range from $86 billion to $190 billion, depending on who’s counting and how. The numbers are staggering, even if we accept the lowest estimates.

And people who drink too much are a $223.5 billion-a-year drag on the U.S. economy. State and federal governments pay more than 60 percent of this bill, according to a 2011 CDC report. More than three-quarters of this cost is incurred by 15 percent of the country’s adults who binge drink.

Within all of this bad news, there are a few rays of hope.

For instance, as of July 2011, only 11 percent of California’s population smoked, down from about 13 percent in 2009. As a Californian, I can say that it is unusual to see smokers – anywhere. And every time a city or other entity bans smoking, there is nary a peep of protest. There has been a culture shift in the Golden State and the tobacco companies have been left behind.

But every state is different. The prize for the lowest rate of smoking goes to Utah. Only about 9 percent of its residents use tobacco products.

On the other end of the spectrum, Virginia wins the booby prize; 27 percent of its population continues to smoke.

Overall, 18- to 24-year-old “Millennials” are kicking the habit more successfully than any other age group, according to Rich Hamburg, deputy director of Trust for America's Health, a nonprofit public health organization. These young adults’ smoking rate has gone from 23.5 percent to about 21 percent in just a few years.

I think Hamburg is right when he adds that the country is at a health care crossroads. The time to shift course is now, and nurses are a key component in that shift.

How nurses can serve as change agents

Nurses must not only be good examples of healthy living, but its most ardent proponents through education. And that education doesn’t always have to be done in a formal setting, either. Without being preachy, we can encourage family and friends to think about their lifestyle choices or we can initiate conversations with patients and families who may be coming for help for seemingly unrelated problems.

Our conversations must proceed with an understanding of patients’ environmental and cultural restrictions, and should be in a positive tone. We should focus on the benefits of healthy lifestyle choices rather than on what might be lost. Changing minds, hearts and habits is a herculean task and requires a culture shift. It can’t be done overnight or even in a few months, but nurses need to set the pace – and we need to start now.

Are you already helping your patients make positive changes?

Do you have any strategies for addressing unhealthy lifestyle issues with others?

Tell us about them.

Am I Sick Enough to Call Out? The Nurse’s Dilemma

By Laura Webb, BSN-RN, MRP

I awoke to the sensation ― no, the profound knowledge ― of choking. Choking on something all too familiar. I was choking on my own blood.

I sat up quickly, struggling to clear my throat of the flood of salty bubbles forming in my esophagus. I felt a rush of warmth from my nose and grabbed it, pinching hard with my right hand, staggering out of bed and feeling my way toward the bathroom as I continued to cough up warm clots into my left palm.

I’ve been a nurse long enough to know that bloodstains are never pretty. And they are a pain to clean! I didn’t want to have to face them later, on my carpet and linens.

My mind was trying to race, but my head was too light. It sent my thoughts spinning. My ideas were not gelling well. Neither, it seemed, was my blood. This was my fifth bloody nose in as many days.

In the midst of it all, my “responsible nurse” side took charge of the situation. I heard myself proclaim that I needed to get back to sleep so that I would be fresh for work in the morning. At the same time, my “practical nurse” side argued, “I can’t go back to sleep! What if I start choking again?”

Meanwhile, a vulnerable inner voice pondered the possibility of going for help. Should I wake up my family? Impose on a neighbor? Call an ambulance?

I eventually managed to get the blood to slow down to a small trickle. The responsible nurse voice encouraged me to take a shower, “as long as I was already up.” But, my sleepy self won and I hopped back into bed, intending to get another hour or so of sleep. It was 3:45 a.m. when I closed my eyes.

As soon as I lay my head on the pillow, I felt my throat fill up again with clots. I sat up coughing, realizing that sleep was not an option.

I thought about work. I had a 12-hour shift ahead of me in the intensive care unit. I knew from experience that I needed to call out soon, if I was not going to make it to work in the morning. In my hospital, day nurses are expected to call out by 6 a.m., at the latest. I tried to recall how much sick time I had available. Would I have to use vacation time to call out? Did it matter?

In the end, I did the most responsible thing. I called out. I even went to an ENT, who stopped the bleed with cauterization.

Still, I felt bad about leaving my peers in a potential lurch. I also worried about the nurse who might have to float to an unfamiliar environment. I was sorry that I wouldn’t be able to tell one of my patients goodbye; she was ready for discharge after several days on our unit, and I might not see her again.

But I couldn’t put my patients or peers at risk. If I was not 100 percent, then it was probably best for me to stay home. I also knew that I needed to take care of myself. My health and safety are also important.

Nurses are notorious for putting others’ needs before our own. But, it is vital that we refrain from risking our own health in our effort to be “responsible” nurses. Sometimes, the most responsible move is to pick up the phone and call out.

Unmasking Mood Disorders: Book Helps Those Who Look Fine but Aren’t

By E’Louise Ondash, RN

Millions of people in this country suffer from chronic and debilitating diseases. It’s easy to spot them if they use a wheelchair, are missing a limb or carry an oxygen tank. But millions have “invisible” disabilities and chronic problems, like those with depression and anxiety disorders. And even though nurses are health professionals, sometimes we either dismiss these maladies as not really counting, or are unaware of them in our family, friends and patients because they look just fine.

That’s the point of “But You LOOK Just Fine: Unmasking Depression, Anxiety, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Panic Disorder and Seasonal Affective Disorder,” written by Sahar Abdulaziz, MS, and Carol Sveilich, MA. The book is meant to be a resource for those dealing with mood disorders (“a support group in a book”) and those who love them. It also serves as a valuable tool for any nurse involved in patient care.

Why a book about feeling one way and looking another?

According to Sveilich, formerly a university student counselor, value judgments are based mostly on what we see. When someone appears to be healthy but is coping with depression or various forms of anxiety, others – including health professionals – often too quickly dismiss reluctance-to-participate as laziness, selfishness, or a lack of interest or caring.

Sveilich knows what she is talking about. Once a professional who could multi-task with little effort, she began experiencing fatigue and pain that escalated to a degree that they interfered with daily activities. She continued to deny there was a problem until she was diagnosed with several serious chronic illnesses. That was more than two decades ago.

“My life was turned upside down,” she writes. “I was no longer capable of functioning at warp speed. My old self…had departed. A new self was taking over. I had to embrace a new normal.”

Sveilich and Abdulaziz, who has Crohn’s disease, want those who don’t struggle with chronic, invisible mental illnesses to understand the profound challenges of people who do. They also want to introduce those with depression and anxiety disorders to others who struggle likewise.

The book is “a safe place where they can find familiar stories, discover new visions for…the future and meet new comrades in their ongoing struggle,” the authors write.

The first part of the book serves as an excellent primer on depression and various anxiety disorders – their definitions, myths, manifestations, treatments, coping mechanisms, and practical advice. The chapters explore, among other topics, the impact that mental disorders have on family, employment and career, social life, and dating and intimacy. They also present treatment options and the connection between chronic depression and pain.

In the second half of the book, readers meet 38 people who must live with the challenge of depression, chronic anxiety, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder, seasonal affective disorder, and combinations of two of these or more. These individuals are featured in the book with their first names and photos and generously tell their stories in the first person. Common themes are isolation, lack of energy and self-confidence, and feelings of worthlessness and alienation.

“When we started, we didn’t know if people would be comfortable in sharing their experiences and emotions in a candid manner,” much less their photos, Sveilich explained, but because they did, “they may help countless others.”

Their personal stories also should help nurses recognize and care for those with depression and anxiety disorders, or perhaps even to cope with their own.

This “Just Fine” book is the second on this topic by Sveilich. It is available on Amazon and other online retail sites, or via the book’s Facebook page, which includes a wealth of additional information on coping with mood disorders.

I Am a Nurse, I Am an Island

By Laura Webb, BSN-RN, MRP

Most nurses value our autonomy at work. Much of our time is spent working independently, caring for our personal load of patients or engaged in a unique administrative role. It is empowering to be “on our own” sometimes.

On the other hand, the autonomy in our jobs can sometimes leave us feeling isolated and alone.

Do you ever feel like you are working on your own, hectic little island? Whether you work at the bedside, or behind a desk or podium, it is important to find ways to reach out and bridge the gap between your patient population or work silo and the rest of the medical profession.

It can be easy to get caught up in our own silos at work. We may be too busy “fighting the fires” that are inherent to patient care. Or, we may not have access to an easy mechanism for connecting with our colleagues.

Social networking sites can help to bridge this gap when we are looking for support and insight about our nursing roles. In fact, they are vital to many of us. But, we must be ever mindful of patient and staff confidentiality concerns and it can be hard to resolve an imminent crisis online.

So, how do we connect to our colleagues in meaningful and timely ways? Many facilities encourage – or require – nurses to round with doctors in order to share pertinent information and develop interlacing plans of care. It is important that we have consistent, timely, honest and mutually respectful means of communication with our colleagues, our patients and their loved ones. Shift-reports sometimes take place at the bedside, for this very reason.

But what about those times when you feel swamped, overwhelmed, or abandoned with a heavy patient load? Who do you turn to for help? Do you have an SOS system (formal or informal) within your facility, or among your colleagues?  Obviously, for severe patient distress we have formal means of calling for help, including rapid response teams and code teams, and formal consults with colleagues and other professionals.

But, how do you handle all those less dramatic, but also exhausting, events at work? Like the JG tube that springs a leak, leaving gastric juices and/or tube feeding fluid all over our patient, or his bed, the floor, or the nurse? What about the arterial line that suddenly dislodges, erupting a pulsating volcano or arterial blood? Even the day-to-day incontinence of a debilitated patient can become physically draining when we are left alone at the bedside, or tending to multiple other patients.

You may also experience technical problems, such as a computer that seizes up in the middle of a med run, or an equipment failure in the middle of a presentation. Who do you turn to in these moments of distress?

Most nurses develop an informal support group at work. We all know and love a few reliable, caring nurses and nurse assistants who will always assist with a bedside crisis. Unfortunately, most of us are also familiar with nurses who disappear in our time of need.

For the most part, however, much of our work ends up being a team effort, and we all know that there will be times when we will be in need of that team support. What goes around comes around, in nursing as in other aspects of life.

How do you reach out to your colleagues for help? Do you have a formal mechanism for addressing informal crises, like “Code Browns?” How can new nurses develop a reliable support system at work?

Let’s hear your stories and ideas -- you can leave a comment here and/or start a conversation on NurseZone’s Facebook page as one way to reach out to colleagues.

Technology Is Wonderful, But Observant Nurses Are Better

By E'Louise Ondash, RN

I love technology.

There are times when I can’t imagine how we ever lived without computers, cell phones, tablets and all the gadgets and capabilities that come with them. All that digital power can be quite hypnotic and euphoric.

But I cringed the other day when I heard a comment by a physician regarding some new devices that enable hospital staff to remotely monitor a patient at all times. The patient wears a transmitting device on the wrist, and the device sends vital signs like blood pressure, heart rate, respiration and others to nurses’ and doctors’ cell phones and tablets.

“The doctors and nurses don’t even have to go into the patient’s room to evaluate their status,” this doctor told the radio reporter.

Ouch.

I think I know what he meant – that with these devices, patients can be monitored more often and more closely because nurses and doctors can access vital signs from anywhere at any time. But I also think this statement is indicative of the false sense of security that technology can give us. There is danger in thinking that the latest gadgets are a substitute for actually observing patients in the flesh.

We all know that there are many factors that can be discerned by a bedside visit, including many things that cannot be transmitted through cyberspace. Bedside assessments can include looking for signs of anxiety and depression; checking the IV; checking condition of the skin; checking condition of the room and placement of the call button; talking to family or visitors and discussing treatments; encouraging fluids; and providing assurance.

Just seeing a nurse come through the door is a source of reassurance.

Technology can also lead to the phenomenon known as “alarm fatigue,” addressed by Gail Powell-Cope, PhD, ARNP, FAAN, and Audrey L. Nelson, PhD, RN, FAAN, of James A. Haley Veterans Hospital in Tampa, Fla., and Emily S. Patterson, PhD., of Cincinnati Veterans Administration Medical Center, Ohio State University in Columbus, Ohio. Their research showed that, with the preponderance of technological devices and their false alarms, nurses and other staff eventually begin to ignore the bells and buzzers, assuming they are false alarms. The Joint Commission even issued a Sentinel Alert last month because this ongoing problem still needs solutions.

So I say “Hooray!” for technology and all it does to enhance care within the acute-care setting, but nurses and other health professionals must never think of it as a substitute for good-ol’-fashioned bedside observation and care.

What technological aids have helped you the most in caring for patients?

What are some of the drawbacks of these devices?

Tell us about it.