New to Nursing : Patient Care

The Art of Listening

Mia Ross — Mon, 13 May 2013 12:13:00 GMT

I learned a valuable lesson at work last week.

As an orthopedic operating room (OR) nurse, my manager constantly has to remind me that we have schedule to keep. I’ve only been working for a few months, but I’ve already been asked the question, “What was the delay in transferring the patient to the room?” multiple times. Though I usually try to make up a logistical excuse, the reason is always the same: because I love talking to the patients and their families in the holding area.

This day, as the holding nurse gave me report, she rolled her eyes as she whispered to me, “This one’s just a doll.” I smiled slightly and nodded in understanding of her warning. Nurses do this for one another. We forewarn to prevent disaster. We urge each other to put on protective gear. I understand there are positive sides to this, but as I approached the patient bed, I made a decision. From this moment on, no matter how high maintenance, loud or angry this patient was I would not roll my eyes. I would be open and honest. I would advocate for her.

As I pulled back the curtain, there was no giant green monster laying in that bed. Instead, there was a sixty year old woman, scared to death about having surgery; a woman probably scared to death about a lot of things. I performed my usual routine assessment. A story began to unfold. The way that she fell was so unfair, she said. So sudden. So debilitating. She was still mourning her accident and humiliated from being completely dependent. I listened actively, said nothing. After a lengthy soliloquy, the patient looked up at me. Her eyes found empathy in mine. That was all she was looking for. After I simply listened, without judgement, the patient decided, all on her own, that she was “ready to get to the next stage of convalescence.” I smiled and said, “then it looks like it’s time to make our way into the OR.”

I was late into the room, again. The anesthesiologist looked impatient. I knew my manager would be on her way. I didn’t care. The patient looked content. There was a look of peace on her face as she drifted off into her unconscious. This is the reason I became a nurse, I thought: to assuage anxiety, alleviate pain, mitigate suffering. If the clock can’t slow for me to do that, the schedule will have to wait. A few minutes of tardiness can cost the hospital a few dollars, but taking the time to listen, really listen, to a patient in need is priceless.

Being the Nurse Your Patient Wants and Needs You to Be

Frank Visco — Mon, 22 Apr 2013 19:50:00 GMT

Generally speaking, I try to be a friendly conversationalist when taking care of patients. I’m a big believer in the personal touch nurse’s can add at the point of care, so I do my best to make connections while providing nursing services.

Most patients I’ve come across seem to enjoy being engaged on the personal level. They like talking about their grandkids or hobbies, and they seem very keen to hear about my schooling or how long I’ve been married or whatever. Not only do such niceties temporarily take patients’ minds off the hardships they may be experiencing, but they also make for a pretty effective ice breaker during some of the more vulnerable activities like sponge baths and bathroom assists. And, I’ve found acting this way can often increase compliance.

That’s the way I prefer to do things, but I’ve come to recognize that adaptability is key to providing quality nursing care. While some patients may appreciate this approach, others are not interested in conversation and would prefer as little staff interaction as possible. And really, that’s not a bad thing. It’s important to try to give the patient the level of care they want.

However, it’s also important to remember that it’s not just about what the patient wants, but also what the patient needs. Sometimes these things don’t align. A patient may not want you there to help them wash up or be repositioned and turned, but realistically, skin breakdown is going to occur if they aren’t. A patient may not want to take a medicine, but it may be vital to their well being.

It can sometimes be a tricky balancing act. Patients have rights, but, at the same time, we have certain obligations. Navigating the waters on this topic is one of the hardest aspects of this job – perhaps even more so than all the skills we have to master and knowledge we have to amass.

Altering Perspectives on Psychiatric Patients

Frank Visco — Wed, 17 Oct 2012 17:57:00 GMT

I finished my psych rotation this past weekend, and in a few days I'll be rolling right into pediatrics. I'm excited to work with kids, and my experiences there will undoubtedly be the focus of my next several blog updates. However, this week, I'd like to offer some final thoughts on mental health care.

There's a perception out there that every patient in a psychiatric unit is severely and theatrically mentally ill. When I tell people I'm doing clinical hours on a psych unit, they instantly jump to conclusions, assuming I'm doing time in some sort of madhouse where every patient is violently delusional, hearing voices, proclaiming grandiose imaginings, enacting multiple personalities, or, at the very least, manically bouncing off the walls.

I'm not going to deny the possibility for some of that, but it's far from the whole picture. The truth is that psych units include many people who would seem totally normal and adjusted in most situations, just as much as you, me, and our loved ones. These people find themselves on psych units for a variety of reasons (anxiety, depression, addiction, eating disorder, suicide attempt, etc.), but their mere presence doesn't make them crazy. All it means is that they they need some help dealing with emotional and/or psychological issues.

You don't have to be a genius to realize there's a stigma surrounding psychiatric care. Most people see mental illness as a character weakness of some kind, but the fact is that psych issues often have a genetic or biochemical basis. Psych issues are very real and the people experiencing them shouldn't be treated as societal pariahs just because they have a bum amygdala or don't use serotonin properly.

In the end, looking down on someone for having an anxiety disorder or crippling depression is just as unfair as judging people for having type 1 diabetes or a heart defect. These are important distinctions, and I think it's our duty as health care professionals to advocate for psychiatric patients and facilitate better understanding of mental health.

Confidence in an Emergency

Alexandra Cosan — Tue, 07 Aug 2012 14:38:00 GMT

As of late, I have definitely been feeling more confident in my care. I do not know if it was the whole milestone "one year" idea that really helped it set in, but confidence was upon me.

This was truly solidified when I recently had an emergency situation with my patient. I was getting ready to discharge this patient when the patient had a new, acute, severe pain. After assessing the patient, having the patient walk (both the MD and I suspected gas pain initially) I obtained another set of vitals as the patient was looking increasingly pale. The patient had become hypotensive. I called the doctor again. He came immediately.

In the meantime I prepared IV fluids and informed my charge nurse of the situation. I also obtained labs on the patient as quickly as possible and knowing that I only had one arm to work with and that I am not the best at IVs, I tracked down a more senior nurse that I knew would obtain 18 gauge access, quickly.

I suppose what gave me confidence throughout this was that the MDs and I were on the same page as far as what was possible happening with the patient. I suspected this patient was bleeding internally based on the surgery the patient had had as well as the fact that the patient had been anticoagulated as recently as that day. It turned out after a CT scan that that was indeed what was occurring.

When you are hustling around for fluids, lab materials, IV materials, pain medicine etc., it is easy to overlook the fact, "hey does this patient have an active type and screen while I'm about to draw labs anyway?"

I am not sure that anyone ever feels totally confident when a patient is acutely ill and has the potential to crash, but it felt good to know the proper steps, remain organized and calm and ultimately get the patient to a higher level of care.

Caring for Dementia Patients

Frank Visco — Fri, 27 Jul 2012 20:29:00 GMT

I’ve been working on a geriatric floor this semester, and although it provides diverse all-purpose care, many of my patients have had one common element -- dementia.

Dementia is never what actually brings my patients into the hospital. Instead, the admitting complaint is usually something like chest pain, cancer complications, or cellulitis. However, dementia usually becomes the key issue I end up addressing as a student nurse.

Oddly, I was thinking about making dementia the focus of this week’s blog post when I discovered this article on the ADVANCE site earlier this week. It’s a really nice reflection by recent graduate Raysha Monel in which she discusses how her experience with dementia patients has inspired her to pursue a career as a geriatric nurse practitioner (I suggest checking it out).

Like Raysha, I have enjoyed my time taking care of dementia patients. Yes, it can be sad seeing a man struggle to remember his wife’s name or stare blankly at a ringing phone, unsure of how to answer it or what it even does. And it can be even worse seeing the reactions of family members – the devastation on the faces of some, the broken down and frustrated apathy in the actions of others.

Nevertheless, I believe caring for dementia patients has been quite rewarding. Obviously, they can get frustrated, confused and/or depressed due to feelings of isolation, but I’ve found it really makes a difference if you take the time to comfort them with some nonjudgmental care, a ready smile, and an attentive ear.

I’m not sure I ultimately want to end up in geriatric nursing myself, but I definitely see the appeal of it. Although they may not be cognizant of it 100 percent of the time, dementia patients still have dignity, and working to help them uphold it is a truly worthwhile endeavor.

Patient Satisfaction: The New Driving Force

Alexandra Cosan — Mon, 14 May 2012 21:37:00 GMT

Our roles as nurses has always been multi dimensional. We do not simply administer medications, perform wound care, etc. We provide emotional support, we advocate, we clean both the patient and the patient's room at times, we encourage, we assist with ambulation--we fulfill many roles for the patient.

So now, in this ever changing economy, and because health care is ultimately a business, we too must move with the change. Hospitals will be reimbursed by the government based on patient satisfaction which is determined based on surveys that random patients receive following his or her hospital experience. What does this mean for nurses? It means now more than ever we have to insure not only that we are delivering high quality care but essentially doing it with a smile as well.

One of our leaders compared it to that of an experience at a restaurant. It does not matter if the food is the best food in the world if the waiter or waitress was unpleasant and/or the service was inefficient. Ultimately, one's memory of that restaurant is going to be that of poor service, rather than delicious food. So, as nurses, although this concept can seem frustrating because we can not always please every patient when there are many factors out of our control that may pain their hospital experience, we must move with the change. It means taking our care to the next level. It means, taking more time to develop a rapport with patients and perhaps while changing that central line dressing with perfect sterile technique, also finding out about that patient's family and what he or she does for fun.

Now this is not to say this was never done before or that many nurses do not already focus on this this, however the difference now is that everyone HAS to. I do believe this will lead to an overall positive, but it certainly will take time.

The Value of CNA's

Alexandra Cosan — Fri, 30 Mar 2012 22:37:00 GMT

A nearby city hospital's recent implementation of an RN centered model of patient care, thereby eventually eliminating CNA's, is certainly a thought-provoking topic. The fact that this hospital's decision to implement such a plan was based on research that concluded that there were better patient outcomes with an RN centered model, would cause any healthcare institution to reconsider its current ways. Although you can not deny this research, I wonder if perhaps there is a way to improve patient outcomes without eliminating the CNA position all together.

Although it would not be easy and it would certainly require an investment, (though hiring more RN's will as well) I think some sort of improved communication model between RN's and CNA's could have a significant impact. Afterall, poor communication between the RN and CNA is what often leads to mistakes and misinformation so if that aspect could be improved and the overall RN/CNA relationship could be improved, perhaps the same improved patient outcomes could result. This model could be shared from the time an RN and CNA orient to the hospital and continually reinforced every 2-3 months. Audits could be completed to insure that accurate information is being passed between RN and CNA and that documentation is cohesive. Managers on each unit could also help this by encouraging social gatherings outside the hospital or unit get-togethers.

This may seem very idealistic, as I am sure it is, but I feel strongly that there must be a way to avoid so many qualified individuals losing employment in a field in which it requires a unique individual. I also am viewing this from the perspective of an RN on a surgical floor. My patient load is typically only four but on the days when we are fully staffed with CNA's I feel that my care is improved because I can focus my care. Four thoracic patients that need three walks in a 12 hour shift is a very difficult task to accomplish without the help of a CNA.

I believe there are countless reasons as to why a CNA is valuable, but one in particular is that it is often a stepping stone to the role of an RN. About half of the CNA's on my unit are in school to become an RN. Without the experience of being a CNA, which many RN's were at some point, how will the patient outcomes be then with new nurses that have less experience with patients?

I hope that other hospitals can come up with more creative solutions if similar research yields the same conclusion.

Reducing Medical Errors

Frank Visco — Sat, 11 Feb 2012 02:05:00 GMT

During a recent stay in the hospital, one of my family members acquired methicillin-resistant Staphylococcus aureus (MRSA). When learning about the medication my relative needs to take as a result, I found myself in a state of shock. Not because he has MRSA, but because I wasn't shocked to hear the news.

Patients with MRSA are specifically put in isolation (or in rooms with other MRSA patients) to avoid the spread of the bacteria, and health care professionals (HCP) are required to wear protective garments when with such patients. However, it's likely many HCPs aren't doing this, because, when being pulled in 100 different directions, it can seem pointless and time consuming to "gear up" when you're just stopping in to get a set of vitals or administer a quick 10am med. I've seen this in hospitals myself, and have even been told by various HCPs that it's okay to forgo the garments as long as you're careful and wash up well after finishing.

Obviously, it's not okay. Patients in healthcare settings are already at increased risk because they have weakened immunity and combining that with human errors and system breakdowns isn't helping the issue.

On the positive side, a recent study in The Journal of The American Medical Association indicates serious invasive cases of hospital acquired MRSA dropped 28% from 2005 to 2008. That's a fantastic development, but it only speaks to the more invasive infections and doesn't even touch on the cumbersome and needless skin infections people like my relative are being saddled with.

The fact is that medical errors (of which hospital acquired infections like MRSA are just a piece of a pie) are a major problem in the healthcare arena, as they have lead to numerous unnecessary illnesses, injuries and even deaths, while also taking a major financial toll on the country. Recent estimates suggest that the United States spends approximately $17.1 billion annually on measurable medical errors, and that such errors increase healthcare costs by 17 percent and length of hospital stay by 22 percent.

Those are heavy statistics, I know, but nurses and nursing students are in the perfect position to help bring those numbers down. Due to our role at the bedside, we are the final defense. Over 11 years ago, the Tri-Council for Nursing released a position paper stating "because nurses work directly with patients and can provide insightful information and perspective on medical error, nurses can play a key role in engineering safer systems. As direct care providers, nurses must be involved in the evaluation, development, and implementation of efforts to overcome medical errors."

That statement still holds true today, and for some errors - preventing pressure ulcers, for instance -- we actually have to be on our game and put the work in to ensure things don't go wrong. But with other errors - errors like transmitting MRSA to patients like my relative -- it can be as simple as slowing down and following simple hygienic procedure.

Continuity of Care and Nurse Burn Out

Alexandra Cosan — Fri, 13 Jan 2012 17:34:00 GMT

On my floor, we often have a patient or two at any given time that end up staying on the floor for more than two weeks. Because we are a thoracic surgical floor the situation is typically that the patient had an elective surgery and it was followed by complications which led to more surgeries. Characteristically the patient is "heavy" meaning they require full care in terms of bathing/toileting and eating/feeding as well as have an entire pharmacy of medications.

With these patients and their families, who are undoubtedly going through intense emotions due to their loved one being in the hospital for longer and much more serious circumstances than anticipated, it was decided that continuity of care was best for patient and family care. From all perspectives both nurse and non-nurse this seems and is, a good idea when executed properly.

The same group of nurses taking care of the patient allows the family to develop a sense of comfort with the care being provided as well as allow the patient to develop more of a routine. If the patient and family is seeing a different nurse every day as the patient's stay prolongs, it usually leads to issues. Different nurses, different habits, not knowing the patient and family as well, all impacts the well being of the patient.

On the contrary, what happens when the patients stay has exceeded 25 days and the same nurse has that patient on night shift because the family made clear of who they did not want caring for their loved one; thus leaving the same nurse on night shift to be caring for that patient? This type of situation leads to a nurse burning out. It leads to job dissatisfaction and there has to be a more open line of communication with the family to explain that the patient has to be shared between more nurses. Ultimately if the assignment is shared between one or two more nurses, the likelihood of burning out the same nurses will be decreased.

This is obviously a very tricky and delicate situation as continuity of care is extremely important, however one can not sacrifice the well being of the staff without first trying to implement more nurses into the continuum.