Thanks for the People Who Have Come into My Life

It’s Thanksgiving week and despite the tenuous state of our economic lives, I have a lot to be thankful for, including the people who have come through my life while working as a nurse and a journalist. Each had something to give, something to teach.

As a nurse, I vividly remember the first time I saw a child die. I was 19 years old and the family looked to me to explain why their 4-year-old daughter died of liver cancer. They taught me that I had better grow up quickly.

And there was the learned Mr. Green in Room 517 who befriended me while I cared for him in a cardiac telemetry unit. I couldn’t believe that he died one morning just before I began my shift. He taught me how to be genuine and that each day is precious.

I remember the 50-something woman patient with obsessive-compulsive disorder whose skin was orange because she’d eat nothing but carrots (true story). We called her the Carrot Lady. She and I had a long conversation about her disorder and when we finished, she decided to have a piece of chocolate cake. She taught me that there are no hopeless cases.

I will never forget caring for the teenager whose car burst into flames when it was rear-ended. He was my first patient in our new burn unit and after months of care, went home with few scars because of the then-new treatment using silver nitrate. He taught me patience and optimism.

As a journalist, I met Robert, a 40-something man with late-stage Hodgkin’s disease who crusaded for the passage of a death-with-dignity proposition in California. The measure, which didn’t pass, would have allowed physician-assisted suicide, much like the current Oregon law. When Robert was barely able to speak, he told me of his disappointment that the proposition failed. He said that he probably wouldn’t do anything to hasten his death, but he’d like to know that the option was there if he needed it. He taught me courage.

Then there was baby Michelle, who had leukemia and needed a bone marrow transplant. I followed her and her family for a year, chronicling what it takes to find a matching donor. They spent days and weeks raising money while trying to care for Michelle’s older brother and maintain some semblance of a normal life. My final installment covered Michelle’s funeral. A year or so later, her mother asked me to write a recommendation she needed for entering nursing school. Michelle and her mother taught me that, sometimes, good can come from bad.

As a journalist I also met many people who made my life richer: the Alaskan artist and adventurer who introduced me to the members of the Explorer’s Club, founded by Sir Edmund Hillary; the Russian-born woman who survived starvation, rape, prisoner-of-war camps and one of the most horrific disasters at sea—the sinking of the Wilhelm Gustloff during World War II; the half-Hawaiian, half-Hispanic, ex-Marine in Albuquerque called Senor Pie because he adds habaneros, jalapanos and chipotle to his apple, peach and cherry pies; an African-American minister named “Gatemouth” Moore who spun stories of his days as a blues singer in Memphis; the woman who worked hard to raise awareness about post-polio syndrome despite her own disabilities; the Mexican mother who traveled with her toddler for almost three days on a bus from the country’s interior so that her son could undergo repair of a severe cleft palate.

Who in your nursing career has left an indelible mark and why?

Tell us about them.

And happy Thanksgiving.

Is Medical Tourism a Good Alternative?

I don’t think I could ever fly to Thailand for a hip replacement or to Costa Rica for a heart bypass, but a lot of people are doing it.

A goodly portion of these travelers are looking for [relatively] cheap face lifts and boob jobs, but there are many others who need life-saving or life-enhancing surgeries, have no insurance and can’t pay cash for these expensive procedures.

Here are some figures to consider, courtesy of the Medical Tourism Association:
In the United States, a hip replacement costs between $40,000 and $50,000. In India, that price tag is about $6,000, in Thailand and Costa Rica, $12,000, and in Mexico, $14,000.

Need a hysterectomy?

In this country, it’ll cost $20,000. Go to India, and you’ll pay $2,300 to $6,000; in Thailand, it's $4,500; and in Mexico, $6,000.

There is one story on the association’s Web site that tells of a 46-year-old Texas man who needed $250,000 heart surgery. He chose to fly to India with his brother and, including airfare and hotel bills, the tab came to $11,000.

By the way, the membership of the Medical Tourism Association is a conglomeration of “international hospitals, healthcare providers, medical travel facilitators, insurance companies” and others — in other words, all the parties that stand to benefit from these international patients. Their goal, according to the Web site, is to promote “the highest level of quality of healthcare to patients in a global environment”— in other words, they’ll do their best for you so that all your family and friends will come on over, too. It’s marketing at its finest, but come to think of it, it’s not much different than what your local physicians and hospital cook up in their marketing departments.

My first instinct, when I heard about medical tourism, was to tell people that they are probably taking a big chance going out-of-country for such procedures, but there are some arguments that may convince me otherwise.

One is that some foreign surgeons have been performing certain procedures longer than U.S. surgeons because the procedures were only recently approved in the United States.

And apparently you get a lot more for your money when it comes to nursing care. Many surgeries come with post-op private duty nurses, translators and plush accommodations.

The downside?

Flying home after surgery could be risky (unless you tack on some vacation to extend your recovery time), and follow-up care can be problematic. But if the choice is between surgery or no surgery, I’ll understand if you call your travel agent.

What do you think of medical tourism?

Is it a viable option?

Have you got a story about someone who sought major surgery outside of the United States?

Tell us what you think.

Question for the Obama Administration: Where and How Will Nurses Fit In?

Most of us have come to believe that words like “lobbyists” and “special interest groups” denote corruption and back-room deals—unless the cause they are pushing is yours. In this case, you’ll be glad to know that the American Nurses Association has its lobbyists working hard for you in the halls of Washington’s legislative branch.

On November 19, the ANA submitted a statement at the Senate Finance Committee hearing on “Health Care Reform: An Economic Perspective.” The statement began softly by praising committee chairman Senator Max Baucus (D-Montana) for “putting forward a vision for health care reform that emphasizes the urgency for action in 2009.”

Then it lowered the hammer: The ANA noted that there was little mention of what role registered nurses would play in the future of providing health care in areas like prevention and screening, health education, cultural competency, chronic disease management, coordination of care and the provision of community-based primary care.

“Simply put,” the statement said, “access to coverage is not access to care.”

You can promise health insurance for everyone, the ANA posits, but who is going to deliver it?

“Registered nurses are fundamental to the critical shift needed in health services delivery, with the goal of transforming the current ‘sick care’ system into a true ‘health care’ system,” the ANA said. “Failure to address issues related to the delivery of care will strain the health infrastructure even more than it already is today.”

A related side note: I heard a piece on National Public Radio this morning in which the reporter cited a recent survey which found that, within the ranks of today’s medical students, only 2 percent say they want to enter the primary care field. It may be that nurse practitioners could pick up some of the slack left by young physicians who are fleeing to higher-paying (and not-so-needed) specialties.

So, will the senators and representatives listen to the people who really know the health care system and what needs to be done to assure that people are able to get the care they’ve been promised?

If legislators are as smart as they claim to be, they will.

If they don’t, they are turning a deaf ear to those who can best help them in what is going to be the humongous, complicated and difficult task of redesigning the health care system.

Do you think nurses are equipped to give advice to those who will be designing health care for the future?

What would you like to tell legislators about nurses’ roles for the future?

Tell us what you think.

Don't "Hi, Sweetie" Me

“Hi Sweetie, how are we doing today?”

I just cringe when I hear nurses talking like that to patients—and especially when they are speaking to older patients. It’s downright demeaning.

I’ve been on the receiving end of such salutations in the hospital and it makes me want to scream. It’s way too maternalistic/paternalistic and makes me feel as if I know nothing, or that the nurse thinks I know nothing.

I realize that sometimes, when people address others as “darling,” “sweetie” and “honey,” that it’s cultural. I remember the waitress at a restaurant in Louisiana’s Cajun Country who approached our table with a “Hi y’all. What can I getcha, sugar?”

I wasn’t offended at all. I know that’s a Southern thing and that she talked to everyone that way, and that everyone talks that way in that neck of the woods.

But when the environment is the hospital and the nurse is the one with the power, the “sweetie greetings” aren’t appropriate.

Apparently not even patients with dementia like it.

That’s what some nurse-researchers at the University of Kansas School of Nursing discovered when they conducted a study of patients with Alzheimer’ disease. The study showed that when nurses used what researchers dubbed “elderspeak,” 55 percent of these patients were “resistant to care.” That compares with only 26 percent of patients who received care from nurses who used normal communication, and 36 percent who received care from nurses who didn’t speak at all.

Elderspeak is defined as using baby talk or talking down to patients, sounding overly-concerned or demonstrating behaviors that suggest being overly controlling. The study, “Linking Communication with Resistiveness to Nursing Care in Persons with Dementia,” was presented at the 2008 Alzheimer's Association International Conference on Alzheimer's Disease in July in Chicago.

Various experts have suggested that there are better ways to approach people with dementia, even when their capacity to think and make decisions has gone. For instance, don’t give choices; just present the single option and do it with respect.

I’m willing to give the benefit of a doubt to some nurses who use this demeaning type of conversation. They are probably just trying to be kind, and perhaps they’ve gotten attached to certain patients, but speaking in a mature tone and treating all patients with respect will go a long way toward decreasing resentment and increasing cooperation.

Are you or your co-workers guilty of using elderspeak when caring for patients?

Why do you think some nurses do it?

Should reminding nurses not to use it be a part of job orientation?

What do you think?

People with Mental Health Problems Need Care, Too

Read a summary of the Paul Wellstone Mental Health and Addiction Equity Act (H.R. 1424) and you quickly understand how messy and complicated democracy and compromise can be.

The act, passed by the House of Representatives in March, will “end discrimination against patients seeking treatment for mental illnesses,” according to the Web site of Speaker of the House, Nancy Pelosi. The bill amends various federal legislation and codes “to eliminate discriminatory provisions that erect obstacles to accessing care for Americans with mental health and addiction disorders.”

It’s all a bit wordy (you should see the stuff I left out), but on the whole, it’s an idea whose time has come. Treat mental illness on the same plane as physical illness and people will get the care they need.

Well, not so fast. Here’s some of the equity act’s fine print, much edited:
• The bill applies only to health plans that already provide mental health benefits (many don’t).
• It prohibits insurance plans from imposing limitations greater than the ones they impose on medical and surgical services. (Sounds good, but limitations are growing every year.)
• It exempts businesses with less than 50 employees and those that experience certain increases in health insurance premiums in subsequent years. (What business has not experienced an increase in premiums?)

The Senate passed their version of a mental health parity bill in September, so now it’s up to the two branches of the legislature to work out something that will make everyone happy—or mostly everyone. Unfortunately, that means that provisions will be pretty watered down.

I haven’t seen the Senate’s version, but the House’s version looks like something that allows congressmen and congresswomen to tell The People that they addressed the problem and came up with a solution. In actuality, the result is likely to accomplish little. All the exemptions mean that, in the end, not many health plans are going to do much more than they do now, which is not much.

Oh, one more thing. Members of the House and Senate, as well as the other 8.5 million people who work for the federal government, have health insurance that pretty well covers treatment for mental health care.

Do you think mental health care should be covered more fully than most policies now offer?

Do you think mental health care should be a part of universal health insurance?

Is the answer to purchase mental health benefits separately and voluntarily, as some health plans are structured?

Tell us what you think.

Marching Orders for the New President

The election is (finally) over and the people have spoken. That includes many nurses who have a wish list for the Barack Obama administration.

“We’re going to be working very hard to make sure nurses stay engaged and that they will be in touch with elected officials,” said Michelle Artz, associate director, government affairs, for the American Nurses Association. “It will be a challenge, considering other issues facing the nation now.”

The ANA is optimistic that nurses’ concerns will be heard because in past years, Obama has come through on issues close to their hearts.

“President-elect Barack Obama has been a consistent champion of America’s nurses,” the ANA said in a statement released the day after the election. “As an Illinois state senator, and as a U.S. senator, Barack Obama has shown a commitment to advancing the nursing profession which will undoubtedly continue as he assumes the highest office in the nation. Barack Obama has promised to work toward improving working conditions for nurses, including limiting mandatory overtime, improving nurse-to-patient ratios, providing additional support to training and incentive programs, and continuing to recognize and support nurses’ right to organize.”

Other issues that nurse-lobbyists will be working hard to keep on legislators’ front burners include universal health care; the nurse shortage; barriers to advanced practice nurses and funding for Title VIII, which provides for scholarships, loans, loan repayment and financial incentives for students and nurse faculty.

“We want to make sure these issues remain on the table,” Artz said, “that nurses remain engaged and in touch with each other.”

The ANA, which says it represents the interests of the country’s 2.9 million RNs, endorsed Obama after “a very deliberate, non-partisan process and only after careful consideration of a variety of factors including: candidate positions and past records on nursing and health care issues; candidate viability in the election; the relationship the candidate has with ANA members and staff; and the feedback of individual ANA/CMA members,” according to association’s online political newsletter.

ANA’s pre-election online nurses’ poll found that 64 percent of the respondents supported Obama; 36 percent backed John McCain.

Are you happy with the results of this election?

What do you think are the most important issues facing nurses in the upcoming years?

What can nurses do in the political arena to promote their interests?

Tell us what you think.

Standardizing satisfaction survey keeps hospitals honest

Let’s be honest.

We usually do better when someone is looking over our shoulders.

Maybe that’s what accounts for the improvement in patient satisfaction scores from surveys that U.S. hospitals are now required to make public.

An Indiana consulting company just released the results of the second group of surveys taken at 1,158 hospitals between January 2007 and June 2008. The company found that the patients this time around gave hospitals more nines and 10s on a 10-point scale than in the last batch of surveys. More of the patients also said that said they would "definitely recommend" their facility.

The first public report on the surveys was in October 2006.

Most hospitals have had satisfaction surveys for some years, but each had its own and the results were proprietary. The Centers for Medicare & Medicaid Services (CMS) decided that consumers really couldn’t compare hospitals when the surveys lacked standardization. To remedy that, CMS and another agency under the Department of Health and Human Services developed a standard survey and mandated that hospitals make the results public. Going public, the agency reasons, enhances public accountability and provides incentives for improving quality of care.

The full name of the survey is the Hospital Consumer Assessment of Healthcare Providers and Systems survey or HCAHPS. It is composed of 27 questions. Two-thirds of them ask about communication with doctors and nurses; responsiveness of the staff; cleanliness and quietness; pain management; communication about medicines and discharge information; and overall rating of the hospital. The remaining questions are administrative.

Many hospital workers and services go into making patients as comfortable and secure as possible during a stressful time. Nurses play a huge role in accomplishing these goals, and it’s the care at the bedside by which patients are most likely to judge the facility.

How do you feel about mandatory public hospital surveys?

Do they put an extra burden on nursing staff?

Do you think surveys are a good tool of accountability?

How does the staff at your hospital learn about the results?

Tell us what you think.