By E’Louise Ondash, RN
I had the good fortune to visit Beautiful British Columbia recently. They call it that without apology because it is beautiful and has everything -- the ocean, beaches, old-growth forest, mountains, glaciers, rain forests and wine country. In light of the controversy in this country about the Affordable Care Act (ACA or Obamacare), I used the opportunity to talk to random Canadian citizens about their health care, health insurance and mandatory coverage.
Full disclosure: As a nurse, I find it difficult to disagree with the goal of providing health care coverage for every citizen. It seems almost redundant to explain why: no coverage, no care. There are many ways to provide coverage for everyone in this county and that’s where many disagreements arise. No system of coverage will be perfect, but the ACA is, at least, getting us off the starting block. (Okay, the Healthcare.gov website problems have made it a bit of a rocky start, but we are on the way.)
Canadians have already been down this road. Federal law there requires that every citizen have health care insurance, and each province has the freedom to design its own rules and types of coverage. It came as somewhat of a surprise to learn that Canadians are not insured under one, giant monolithic system, even within the provinces. Canadians acquire health insurance through many avenues.
For instance, one man in his early 50s said that he is covered under his wife’s policy. She is a nurse and the terms of coverage are negotiated between the hospital and the nurses’ union. He was more than satisfied with their health plan, but acknowledged that if you need an elective procedure like a knee replacement, you will wait. A board of physicians decides your place in the queue.
Another man I spoke with was a low-income musician in his late 50s. His premiums were subsidized by taxpayers, and like others who cannot afford to pay premiums, he is enrolled in “the provincial plan.” This is a low-cost, no-frills policy, but he was glad to have it. He is not responsible for any medical charges that he incurs, and he also said that he doesn’t abuse the system. “I only go to the doctor when I have to,” he told me.
A third Canadian with whom I spoke was a single woman in her early 60s who paid for the provincial (cheapest) plan. When it comes time to pay her premiums, she said, “I don’t even think about it. It’s something we have to do and I’m glad to have the coverage.”
One last example: A low-income, single mother of two who lives in a rural area told me that she and her children are enrolled in the subsidized provincial plan. “If it weren’t for that, I don’t know what I’d do,” she said. Nevertheless, she was upset because the nearest hospital is probably going to close because of fiscal problems, and if that happens, she will have to drive at least 30 minutes for care.
All of these Canadians must buy separate policies for drug coverage and services like physical therapy, or pay for them out-of-pocket.
Shortly before we left for British Columbia, I had the bad fortune to spend six hours in outpatient surgery. The bills for this one-quarter-of-a-day in the hospital totaled about $25,000. The hospital billed the insurance company, knowing it would never see full reimbursement. In the end, my insurance paid about $9,000 and thankfully I am not responsible for the difference. With no insurance, I would’ve been responsible for the entire $25,000, and we all know what’s wrong with that logic.
I hope that someday our medical bills reflect reality, but I don’t expect it to happen soon. In the meantime, assuring that everyone has health insurance is a good thing because, in all likelihood you will get sick or injured at some point and incur large bills.
Canadian health care is not perfect, but at least no one worries about declaring bankruptcy because of medical bills.
Do you think nurses should take a stand for or against the ACA, or remain neutral?
Have you had any medical bills that threatened your financial stability?
Tell us what you think.
Friday, December 6, 2013
By E’Louise Ondash, RN
Wednesday, October 30, 2013
By E’Louise Ondash, RN
Non-compliant patients are the bane of the health care provider’s existence.
My nurse colleagues complain about them all the time.
“Why don’t they just do what they are supposed to do?” they chant. “It would make things so much easier and they would be so much healthier.”
I agree; in a perfect world, all patients would do exactly as they are told and it would be a whole lot easier on us.
I thought about the non-compliance problem after reading a feature written by Ivan Semeniuk, a science reporter for The Globe and Mail in Toronto. He interviewed Eldar Shafir, a professor of psychology and public affairs at Princeton University. Shafir’s most recent work looks at why the poor seem to make bad decisions which usually have negative impacts on their lives.
What Shafir found was that “those who are living on meager incomes are often frantically juggling resources – money, time and health – in a high-stakes game where the consequences of making an error can be severe.”
Such juggling of time and money requires a lot of energy and can be exhausting. It leaves few mental resources for dealing with tough decisions.
“Scarcity focuses our attention to the exclusion of all else,” Shafir explained. “Scarcity…tends to block out competing demands.”
Nurses need to think about this when working with low-income patients, and even with those who may be financially stable but have a scarcity of time and rest because of the demands of job and family. In my experience, though, higher-income patients are generally better educated about their health and the health care system; feel more empowered; and tend to be more compliant than low-income patients. When the chips are down, they at least, unlike the poor, have more resources (people and money) to call into play.
The poor and those who are losing ground in the middle class face many obstacles when it comes to obtaining health care: fewer and more confusing options for insurance coverage; unreliable transportation to appointments; the high cost of medication and good food; lack of support networks; the challenge of caretaking; and potential job loss or underemployment. Financial struggles are a huge distraction, so these hurdles usually appear higher on their priority list than compliance.
But without compliance, health problems only intensify.
If you work with lower-income and/or struggling middle-class populations, have you encountered problems of non-compliance?
If so, have you been able to help solve any of their “distracting” problems?
Tell us about it.
Friday, September 13, 2013
By E’Louise Ondash, RN
The more I read and learn about medicine of the future and new ways of delivering health care, the more I feel that the number of jobs for nurses is going to go only one way – up. And although there will be some new jobs in acute care, the largest growth in employment opportunities is likely to be in a wide variety of outpatient arenas, in long-term and chronic care settings, in patients’ homes, and in phone consultations or telemedicine.
Some of these “new” jobs have already appeared.
For instance, every week around the country, large retail stores like Target and drug store chains like Walgreens establish walk-in clinics (also known as convenient care clinics or CCCs) that are staffed by nurse practitioners who diagnose and prescribe. They see adults and children and treat minor ailments like ear infections, pinkeye and urinary tract infections; give immunizations; and perform camp and sports physicals. Some nurses in CCCs have even assumed the responsibility of monitoring and advising patients with chronic diseases.
According to a 2008 survey by Deloitte Center for Health Solutions, this form of primary care is most popular with “millennials” – those who have come of age around 2000 – but an average of 20 percent of all age groups say they would or have received care at a CCC.
The increasing complexity of obtaining health care also has given rise to the patient advocate or “navigator,” both ideal jobs for nurses. The nature of our profession dictates that we be patient advocates, and our education and work experience is our on-the-job training for becoming a navigator. Nurses also are flexible and resourceful – necessary qualities for dealing with third-party payers and increasingly specialized health care providers and institutions.
As more people live longer and with more chronic illnesses, the concept of coordinated or team care becomes important, and nurses make ideal team members. Team care is necessary because it’s impossible for one health care provider to meet the multitude of needs of the long-term chronically ill. Nurses are invaluable components of these health care teams because they understand patients holistically, and serve as patient advocates and communication links between patients and teams.
The public health arena is another area where nurses will find an increasing number of job openings especially in health education.
According to a statement by the American Nurses Association, health care in this country is currently shifting its emphasis from an “illness care system” to one focused on health promotion and disease prevention. This change of direction is occurring because of the “convergence of multiple economic, political, and social factors,” including the Patient Protection and Affordable Care Act (ACA) and other federal legislation focused on preventive health.
The brave new world of medical technology, mobile devices, and a plethora of health care apps afford opportunities for nurses that didn’t exist just a few years ago. New electronic monitoring devices and apps allow providers to personalize care, increase compliance and lower costs by decreasing hospitalizations and emergency room visits. Patients report to nurses and also look to them for guidance. And medical practices that offer email or other online communication with their physicians often have a nurse available for virtual triage or consults.
All of these new jobs require that nurses do their part – obtain higher levels of education that focus on clinical care, as well as participate in continuing education. It’s up to the powers-that-be to recognize the huge and important role that nurses play in pursuing the country’s health care goals – to increase quality of care, promote prevention, and decrease costs – and to provide them with the tools and autonomy they need.
Do you work at one of the new-generation jobs?
What new nursing specialties do you see on the horizon?
Tell us about it.
Wednesday, August 28, 2013
By E’Louise Ondash, RN
It is said that doctors make the worst patients. Having cared for a few, I’d have to agree that this is mostly true. Physicians are used to running the show; they don’t take easily to taking directions or not being in charge.
What about nurses?
Although most nurses would also say being in charge is definitely preferable, I think they are probably better patients overall. At least I think I’ve been a pretty good patient, and my declaration is based on personal experience; I’ve had more practice at being a patient than I’d like to remember.
Up until my mid-20s, except for a tonsillectomy and having a baby, I managed to avoid the hospital. Then I had a bad accident that put me on the other side of the bed for a month, followed by several months recuperating at home with a lot of help.
As a nurse-patient, my body of knowledge was both a blessing and a curse.
Having worked in acute care, I knew how a hospital functioned and what to expect. As a nurse-patient, I didn’t feel like a stranger in a strange land. But it meant that I knew the possibilities of all the dangers and pitfalls, as well as the impediments under which those who cared for me labored. I knew that the unit’s nurses and aides were likely to be understaffed and overworked, so I was reluctant to “bother” them unless it was absolutely necessary.
I also was aware of what the nurses and aides said about “difficult” patients during change-of-shift reports or while on their breaks, and I didn’t want that difficult-patient label.
On the flip side, I made a point to identify myself as one of their own. I hoped that this would get me a little more attention and consideration – perhaps even a few favors. At the same time, though, I didn’t want to appear as though I were playing the “nurse card.”
You can see the fine line I had to walk.
Maybe I didn’t give the staff enough credit, but I couldn’t avoid analyzing my situation or my correct role as a fellow caregiver who was now in need. All of this probably was over-thinking on my part – a product of my youth and insecurity, not to mention my fear and frustration. And with broken bones and internal injuries, my helplessness was a scary thing.
Unable to move, I was completely dependent upon my caretakers. I worried about my call button slipping to an irretrievable place. I watched the clock, not wanting to request more pain meds too soon, but not wanting to wait too long.
I felt I had to keep track of every element of my care.
Looking back on it, I wouldn’t wish that kind of experience on anyone, nor would I choose it if given the option, but being a patient was a valuable experience for me. It brought greater understanding of what it’s like for patients, and certainly more empathy and sympathy for all those in hospital beds who depend on us. Other nurses have told me similar stories.
Have you ever been a patient, and if so, what did you learn?
Do you remember any one nurse or aide who was particularly helpful?
Tell us about it.
Tuesday, August 13, 2013
By Laura Webb, BSN-RN, MRP
How many times have you had one of those exhausting shifts, or a series of exhausting shifts, when you were too tired to even find the words to describe your fatigue? Clichés like “bone tired” and “totally wiped out” can’t quite describe the depth of a nurse’s exhaustion after 12 hours of running and lifting, communicating and documenting--all while caring for a heavy load of patients whose lives may be literally in your hands.
It may seem insensitive to think of ourselves as “dead on our feet” when caring for patients who may be facing life-and-death struggles, yet there are times when that is exactly how it feels!
What is burnout?
We sometimes use the term “burned out” to describe nurses who seem especially dragged down, physically and/or emotionally, from the constant stress and chronic fatigue of our profession. Numerous researchers have studied burnout among nurses, especially in hospital environments. Perhaps burnout is best described as a kind of unresolved stress that accumulates over time until it becomes unmanageable.
I would venture to guess that most experienced nurses feel like they have a lot of expertise with burnout, as well--either from personal experience or from observing it among colleagues.
Burnout is often used to describe a combination of symptoms and behaviors that may include irritability, extreme fatigue, bullying, inappropriate humor or chronic call outs. However, some of these behaviors may be temporary, or simply due to short-term stressors in our lives.
So what is real burnout, and what can we do about it?
In 1981, UC Berkeley Professor Christina Maslach and colleagues published the Maslach Burnout Inventory (MBI). This 22-item questionnaire is a popular measurement tool that is still in use today.
Maslach’s model describes burnout as a syndrome consisting of three primary dimensions or subscales:
1. Emotional exhaustion - a sense that we are overextended and exhausted from our jobs;
2. Depersonalization - a callous, unfeeling response toward clients; and
3. Reduced personal accomplishment - a sense of incompetence or lack of success in our work.
What causes burnout?
While every professional faces certain stressors, most of us employ coping mechanisms to manage that stress. Burnout occurs when stress becomes too much for a nurse’s usual coping skills.
Nurses are often on the frontlines of healthcare, working long hours directly with patients who are often in physical or emotional distress. Our jobs can be physically and emotionally exhausting. We work in close quarters and unpredictable environments with other nurses, and our shared stress can lead to even greater pressure that affects everyone around us.
Certain workplace settings may be more prone to causing burnout than others. Short-staffed, high-acuity and dangerous environments can seem like pressure cookers. Meanwhile, there is no room for error; we are talking about human lives, after all! And so the pressure builds. Or if nurses feel that they lack time or energy for optimal performance, or feel a lack of respect or appreciation from peers or patients, these feelings can lead to frustrations and burnout.
What does it look like?
Physical signs of burnout include exhaustion, insomnia and various aches and pains. Some nurses develop high blood pressure, changes in appetite or a tendency toward accidental injury.
Psychological signs include irritability and depression, anxiety and withdrawal, guilt and cynicism, and a lack of enthusiasm. Nurses may have trouble concentrating or even develop addictive behavior.
Burned out nurses can become socially strained. Communication may suffer. These nurses may act hostile or overly critical of colleagues or friends. They may neglect their families or social obligations, or experience marital problems.
The cost of burnout is often high, and it tends to have a ripple effect. It can lead to unhappy or unsafe patients, high rates of nurse turnover, and personal distress among staff.
What can nurses do?
In order to prevent burnout, it is important that nurses and administrators are able to talk about the issue. We need to be aware of its dangers and have enough self-awareness to notice the signs in ourselves, and our colleagues. And then we need to speak up and address it.
It is also important for nurses to maintain a healthy perspective by pursuing interests outside of work. We also need to take care of our own needs and manage our stress in positive ways; at a minimum, we should be eating healthy diets and getting enough exercise and rest.
Finally, we need to be honest with ourselves. If we find that our current job situation is causing too much stress, we may need to pursue other positions in order to avoid personal burnout.
Monday, August 5, 2013
By E’Louise Ondash, RN
It was a sad coincidence recently that while writing a feature on nurses as palliative care specialists, one of my sisters died. She would’ve been the perfect candidate for a palliative care expert. My sister suffered from several chronic diseases, knew that her condition would never improve, had several hospital admissions a year, had a DNR order, but wanted to live as high-quality a life as possible.
Sadly, the services that my sister really needed weren’t available because of politics, too few nurses trained in this area, and a lack of understanding of the benefits of long-term palliative care.
One of those benefits would have been a more focused approach to medication management, which could have helped her avoid some of the multiple hospitalizations. This and other palliative care measures would have been good for her; they would also be good for others with similar problems, and good for the bottom line of all third parties that must pay the expenses of caring for the chronically ill.
So why isn’t palliative care catching on like a ball of fire?
Well, for one, discussing palliative care is, for some, tantamount to saying that the health care world is giving up – that there is little more to be done for a patient. This is totally erroneous, of course. For another, according to the experts I interviewed, it is Americans’ attitudes about politics, money and death that stand in the way.
Fearing offending their constituents or being labeled “death-panel” advocates, here is what politicians and health care leaders will not say: This country doesn’t have enough health care dollars to give everybody everything forever.
This is not an anti-life, anti-religious, progressive point of view; it is simply an economic reality and dilemma that must be reckoned with by politicians, health care professionals, religious leaders and everyone else. The advances in science and technology have presented us with ethical questions that weren’t even dreamed of a few decades ago. Back then, we didn’t have the ability to prolong life that we do today -- and I’m not just talking about ventilators and organ transplants. We now have medications and procedures that allow us and all those we love to live longer-than-ever lives with diabetes, heart failure, cancer, COPD, arthritis and more.
The cost of these extra years is mounting exponentially and we face additional decisions about expensive treatments for those of advanced age. Should we perform bypass surgery, joint replacements, cancer surgeries and chemotherapy regardless of age and outcome? I recently read about an 82-year-old man with prostate cancer who decided to undergo a new form of chemotherapy which cost $80,000 a year. It would possibly extend his life up to 12 months. He chose to proceed, he said, because his insurance would pay for it.
I imagine there were many heated conversations at dinner tables and over water coolers over this case, but there seemed to be an absence of any official discussion.
Can we afford to provide limitless health care for all with our limited resources?
Should we have thoughtful, universal guidelines about paying for care with public dollars?
When will we decide to decide?
None of these questions are easy to answer, but in the meantime, or maybe forever, we should focus on how to make quality palliative care available to those who could benefit. In doing so, we all will benefit.
Tell us what you think.
Monday, July 22, 2013
By Laura Webb, BSN-RN, MRP
It’s hard to believe that only a few years ago, as a nursing student, I wore a starched-white uniform trimmed in deep burgundy tones. The outfit included a white pinafore smock, attached to the front of the bodice with large, white buttons. This smock was designed to serve as a kind of bib, unbuttoning from the uniform at the shoulders and waist for ease of laundering.
As a new nursing student, I was thrilled to don my first “real” nursing outfit, but I soon realized that I was definitely not headed for any glamour shots in that uniform. It never failed to attract comments, and a few comical looks, from experienced nurses.
I wore the uniform to clinicals for over a year before our school decided to upgrade (and join the rest of the 21st Century) to a more modern look. The new uniform colors did not change, but these were more burgundy than white, and the scrubs were much more modern in appearance.
I was certainly more comfortable, physically and emotionally, in this new student uniform. It felt good to blend in with the other hospital staff. I no longer had to endure comments or stares. And, I no longer spent my mornings ironing the smocking on that snow-white pinafore.
While I no longer felt conspicuous, I also experienced a bit of a let down with the new uniform. I sensed a loss of individuality. After all, non-descript uniforms like scrubs can make everyone look and feel the same.
That sense of a lost (or blended) identity not only impacts the individual nurse. It can also affect patients and their guests.
How many times have patients told you that they have trouble telling “who’s who” among the staff? I often hear patients say that they don’t know if they are talking to a nurse, a doctor, or a member of the housekeeping staff. And no wonder! We are all walking around in some kind of scrubs.
One of our most senior professors in nursing school fought to keep the original uniform intact. After we adopted the newer, scrubbier outfits, she would often shake her head in dismay and sigh, “I can’t tell the patients from the nurses these days. They are all going about in their pajamas!”
Soon after graduation, I was pleased to discover that scrubs do not have to be boring. There is a huge assortment of scrubs available, from colorful patterns to tailored duds. Once again, I could feel unique in my work attire, without feeling too conspicuous.
Some of my colleagues refer to these as “designer scrubs” and stubbornly refuse to buy them. But, I like to think that these scrubs are both professional and unique. A nicely designed set of scrubs does not have to be expensive or gaudy.
We often hear that professionals should “dress for success.” Like it or not, our appearance sends a message to others: our patients, their loved ones, and our colleagues. And, I feel better about myself when my clothes fit well, and are neat and clean and attractive – even when my clothes are scrubs.
But how far should you take it? I know nurses who iron their scrubs before every shift. While I would never go to work in torn or wrinkled clothes, I rarely resort to ironing my scrubs. In most clinical environments, scrubs will not stay pressed for long, and I don’t want my clothes to interfere with my ability to “roll up my sleeves” and work.
Do you think that a well-pressed uniform is important? Does your facility require a certain color of scrubs for each service (e.g., pale green for OR or blue for food service)? Do you opt for “designer scrubs” if they’re allowed?