Forming Habits

Some brief thoughts on forming habits:

When you're up against a timeline and every step, every delay is another minute lost, it's easy to do the things you swore you'd never do. One starts to think about one's tasks in terms of getting all the boxes checked, all the paperwork done before an hour after the shift is over. The focus shifts so easily from the overall patient goals to merely completing the treatments that you are responsible for.

As I learn to become more efficient in my nursing, I adopt timesaving methods and actions. But one must be careful not to trade time for safety.

When I identify areas where I am tempted to act sloppily or unsafely in order to save time, I have a choice to make. Either I can allow myself to continue, or I can deliberately decide to take the longer, correct route. Even if it would make no difference in the initial situation, the choice I make lays the foundation for a habit.

These choices can regard small, relatively insignificant areas, or interventions so significant that I am terrified that I even considered the "easy" route out.

Example: I am hanging an IVPB antibiotic and accidentally touch the sterile spike to my gloved hand. Did I actually think about not getting new tubing and starting over? Of course, I go back and get new tubing rather than risk contaminating an intravenous infusion, but what if I hadn't consciously decided to value safety over time?

Any number of similar scenarios of varying importance exist; Patient needs immediate transfer to commode - no gait belt in room. Foley insertion - sterile field broken mid insertion. End of shift documentation, treatment record indicates lotion application for this shift. You didn't do it but the NA probably did - do you sign?

As an RN student, one tends to underestimate the commitment to one's patients necessary to maintain integrity in a hectic nursing floor shift. In my current position as a staff RN, it is only my conscience and a dedication to optimal outcomes for my patients that prevents me from taking shortcuts that have potential to harm either my patients or my integrity. I am deliberately forming the habits I want to define my career; I want to take the extra time to ensure that I help and do not harm.

Getting My Sea Legs

Many days have passed and I have changed as a nurse since I last wrote here. My orientation ended in August, and with it ended my ability to hide behind the ultimate responsibility of my preceptor. I was the nurse. I could go to my coworkers for help, advice, or resources, by my patients, their needs, treatments and tasks, were up to me.

The first two weeks were an agony. I had five to six patients every day and had a patient who was "going bad" almost every day. Two, we had to send out to E.D. Each shift I ended up staying over two and a half to three hours extra to finish the paperwork I hadn't even had a chance to start until the shift was over, piecing together the day from notes in my pocket, reviewing orders, and tying up loose ends. Exhausted, I wouldn't even attempt the 50 minute drive home, but would crash on my parents' sofa and go home in the morning. Thankfully, I didn't have many shifts in a row - I would spend 12-16 hours sleeping after consecutive work days.

Slowly the situation improved. Staffing ratios dropped to 4 patients more days than not, and even 5 didn't seem so difficult. Soon I started having two good days to every bad day, and sometimes I had half my paperwork done before the shift was over. Still, I couldn't see how other nurses managed to sit at the desk for what seemed like hours and still have all their work done by shift change. I began setting goals with the end of being able to leave the unit at 1930.

Finally, one day, it happened. I had all my paperwork done and was out the door at 1925. That week, I left before 2030 every night. Other than typical frustrations, I was in no distress. I did not hide in the bathroom to cry (as I had done each shift for the previous weeks). But now I had nightmares every night, even when I wasn't working; I would forget a patient. I would contaminate an I.V. I would do something wrong, someone would die, the manager was angry with me, I had overdosed a patient, I had given blood without consent, a patient was choking on his own phlegm and I couldn't seem to get the suction catheter into his tracheostomy. I would wake up sweating, and once, screaming. Dreaming was worse than working.

But this past week, even that changed. I stopped dreaming of botched up nursing tasks. I didn't dream of the unit at all, thank God. I began to feel glad to come into work, and actually miss my work when I had a day off (though, I would rather be with my husband than my coworkers any day). It is good not to feel anxious before an upcoming shift, or fear what the next day may bring.

How did it happen? How did I become more comfortable? How did I learn not to fear making horrible mistakes?

First, by God's mercy and protection. I don't know how I made it through the worst of culture shock and initiation, but somehow I'm finding myself on the other side with each day better than the last.

Second, by practice. With time, I have learned more effective and efficient processes and task sequence for each type of patient. Certain tasks have become second nature, and I am learning to prioritize care more appropriately. I have started to establish a routine of activities for the shift that "works" for me and my patients. As I become more proficient in routine tasks and as I encounter and successfully accomplish more specialized or complicated tasks, I become more confident in my ability to provide care.

Third, by actually making mistakes. No, I have not done any of the horrible things I've dreamed about, nor has anyone suffered physical harm at my hands. But I am human, and I have erred. But each error is a choice and an opportunity. A choice of whether to acknowledge the error and correct the error or keep quiet and deny it's occurrence, and an opportunity to learn to avoid the error in the future and implement better practice. One would think the choice would be easy. Of course you should acknowledge your mistake and correct it. But it is not easy. To admit that one has erred in these regards is essentially to say that one has acted contrary to one's responsibilities as a nurse and that one has no excuse. Thankfully, I am gifted with a rather overactive conscience that will give me not rest unless I appropriately address what I have done wrong. With each mistake and it's proper solution, I become less afraid of that mistake - not because I regard it as less serious, but because I know how to avoid it and that if it does occur despite my best efforts, I can address it and will survive it.

I'm sure there are more factors that have contributed to my increasing comfort with my work. For now, it is sufficient that I have begun to feel that the I am doing good work and fulfilling my job responsibilities. I'm am glad to have reached this point. Each day I learn something new. It is my goal to begin to share these lessons here.

Till Next Time

Culture Shock of the New Graduate RN

After two months of orientation as a Registered Nurse Intern (Graduate Nurse)on a Long Term Acute Care Unit, I've finally taken NCLEX and I'm finally beginning to face my culture shock.

The honeymoon is over. I'm beginning to ask myself whether I really want to be a nurse after all. Or, more truthfully,whether I really want to be a nurse at LTAC. Unit jumping would be very, very tempting right now. As the reality of the unit culture rubs itself in my face, I tell myself that there has to be a place where things are done more efficiently, more safely, more pleasantly. Maybe in E.R. Maybe in O.B. Maybe in Critical Care. Maybe at another organization altogether.

Then I remind myself that every healthcare job in every location has difficulties, a culture to adjust to, problems endemic to its staff and management. I tell myself that culture shock is a stage of my new life as an RN that I must pass through, I must weather. To jump ship right now from LTAC would merely delay the crisis that must come to me on the next unit. Until I come out the other side of the nursing culture shock (or become entirely broken in the process) I feel I must hold my course.

So I have pledged myself to remain in this position (unless God clearly intervenes) for at least 6 months, preferably the more appropriate 9 months from hire. I feel I ought not to do otherwise by my employer than give the work for which I was hired. I also feel that in doing so enough time will have elapsed to allow me to more accurately judge whether my distress is truly a product of this particular work environment or merely arises from the inevitable culture shock of the new graduate nurse.

What is it that troubles me, then, about my job? Since I have clearly indicated that I am troubled.

It is the constant sense of inadequacy and futility against the wave of human ailment that surges against me. It is the limitations of my memory and time management. It is the revulsion of my mind against tasks which I must perform, not because they are intrinsically valuable, but because they are printed on a sheet which I must sign. It is the panic of my conscience against the crush of time which prohibits the detailed inquiry, precaution, and care I have been trained to undertake.

I hesitate to be specific about the above. Much of the specifics do not make sense outside of the context. One must live in that context to understand and justify the apparent travesty.

The ideal world does not exist: for nursing no less than for any other profession. All day long we fight therapists for access to our patients. Can I do a dressing change for Mrs. Smith? No, Mrs. Smith is having occupational therapy. Can I take Mr. Joe's blood sugar? No, physical therapy is walking him in the hallway. Assessments, dressings, medications, treatments -- all are displaced by a rush of Physical Therapy, Occupational Therapy, Speech-Language Pathology, Respiratory Therapy, Hyperbaric appointments, Dialysis, X-Ray, Phlebotomists, Physicians, Families, Visitors... I am learning to be pushy and possessive of my patients.

And items kept where one needs them? Everyday, I have to call Pharmacy for something not sent up for a patient: from Vitamin C to Venofer, from Culturelle (basically yogurt pills) to Vancomycin (a top of the line antibiotic).

It is true, I am clumsy and not very quick. But this is the kind of work where one cannot afford to lose even a few minutes of the 12 hours one has to work with in a shift. I must strike a careful balance between deliberate double checking and prompt decisiveness. I cannot afford to overlook anything, and yet, I cannot afford the time it takes to identify every consideration.

Perhaps it is also discouraging that I work in a setting where the very nature of the patient body prevents me from receiving visible affirmation of the benefits of my efforts. As my preceptor frequently tells me, "These people are chronic." Many never regain their health completely; we keep them from worsening and help them learn to cope with their conditions. Frequently, we have patients for months at a time, some of whom ask me every day, "When can I go home?" We get the sickest of the sick -- not at the moment of crisis, but in the gradual decline brought on by years of self-abuse, lifestyle choices, or unfortunate genetic and physiologic tendencies. When everything has been done for them, they come to us, to finish out whatever we can do. While I don't have a statistic to back this up, my estimate is that one fifth of our patients will die in the next year. It seems that at least every month I hear of another patient I've interacted with at some point in the past year since starting to work at LTAC who has recently passed. And for a while, the morgue's vehicle seemed to be at least a monthly visitor.

Of course, these aren't all our patients. Many come to us for conditions that we can fix -- with time. These patients become stir-crazy and bored, even when they are getting better. As their wounds close in and heal, they become more and more anxious to leave, and more and more frustrated when they cannot yet. Yet, we do have some pleasant patients -- people who understand our limitations as well as their own.

For all of our patients, our work is important, thought it can be difficult to see this, or appreciate it. It is easy to become cynical with myself and my inability to provide for my patients what I feel is the best I can give. Yet, I must try. Every day that I work I must try. God will do what He wills with my work - and my culture shock.

Provider - Patient Ratios

Staffing everywhere is tight. It's a reality of the economic downturn coinciding with a large population of aging patients on Medicare/Medicaid needing labor-intensive, expensive services and care. Nobody - patients or staff - enjoy an understaffed shift. However, frequently understaffing is an unavoidable reality. Here are a few thoughts on the reasons administration should take action to address understaffing and strategies patient care providers can use to maximize their effectiveness on an understaffed shift.

Why maintaining adequate caregiver-patient ratios is critical:

1. Patient outcomes.
The reality of human experience is that one person can only be in one place at one time and can only accomplish one task at a time. If there are five soiled total-care beds to change and one person to do the job, some of those patients will lie in excrement for the better part of an hour. There comes a point where, no matter one's efficiency, one cannot physically provide certain aspects of care to all one's patients. The question becomes not, "How best can I ensure that this person's bodily needs are met?" but rather, "What is the minimum I have to do to keep this patient from deteriorating on my shift?" Obviously, this attitude doesn't promote optimal patient outcomes. It rather begs the question, "If our patients are not able to get sufficient care to improve and return home (or wherever their destination), then why are they here?"

2. Staff Morale.
When a unit is consistently understaffed, morale among providers of direct patient care becomes very low. I think this drop in morale has a twofold basis. First, a "good" provider is put in an unsolvable quandry of "prioritizing" to the point of foregoing important aspects of care. The provider for whom quality patient care is a priority physically cannot provider quality care. He (or she) tries desperately to perform the duties of his job, but at the end of the day must admit to himself that he has failed to adequately fulfill the responsibilities for which he was hired. He is justly unsatisfied with his work and unhappy with the results. In this way, normally excellent caregivers are crippled and spiritually mutilated. Eventually, staff either burnout and leave or become cynical and insensitive toward their patients. What else can one do when one is forced to tell patients that they will have to wait to have their basic needs met?
Second, staff may lose trust in management. They feel helpless to perform their jobs appropriately and may become angry. When concerns over low staffing are voiced and no changes are made, staff begin to feel that management "doesn't care," or "they don't know what it's like," or "nothing I say will make a difference," or "they just won't do anything about the staffing problems." This attitude obviously impairs the work environment and the effectiveness of both staff and management. It propagates a defeatist attitude toward appropriate "chain of command" communication and is toxic to worker positivity.

3. Patient Satisfaction
Ultimately, the expertise of medical care doesn't much impact patient attitudes about the care facility. Many of my patients haven't a clue whether their pressure ulcer needs a wound vac or a colostomy. If you tell them that's what the doctor has ordered, most of them would agree. What they do care about is promptness in answering their call, adeptness at meeting their basic hygiene needs, a cheerful attitude, and time taken to discover who their are as an individual and deliver personalized care. A nurse or nursing assistant who is able to to deliver such care hugely increases patient satisfaction with the hospitalization experience. When call lights are not answered for twenty minutes, baths are not given when asked for, food is late or cold when it arrives, staff runs in and runs out after asking the obligatory, "Is there anything you need?" in a tone that clearly indicates they are hoping you won't need anything, and none of your caregivers have time to talk with you or hear you out, you as a patient end up feeling uncared for, insecure, and unsafe. "What if I really needed help?" they think. "I couldn't depend on anybody here to answer my call light. Why am I here if they're not going to help me?"

Strategies for Improving Effectiveness on an Understaffed Shift:
That said, here you are, one of two nursing assistants caring for 25 patients on a unit where over half of your patients are total care, many are incontinent, several are confused or have dementia and a couple are agitated enough to be in soft restraints (like mitts) and need close observation. You have twelve hours. Go!

Prioritize. In this case, that means "ration" yourself. Round as quickly as you can and make a general assessment of the condition, independence level and needs of each patient. Then focus on the incontinent patients. Get them cleaned up and dry. To be honest, that (and answering the omni-present call lights) may be your primary activity all day long. If there are patients who are constantly "on the light," it is probably in your best interest to try to take care of their needs all at once, even if they are not your highest priority patient, because answering their light all day long will take longer than taking time away from your other patients now. It may be heartbreaking, but sometimes it is necessary to tell patients that they will have to wait a while but you will get to them as soon as possible.

This is often the case with incontinent patients who are cognitively aware. You are in the middle of washing a frail, thoroughly soiled patient with several now contaminated ulcers and have to step out of the room for additional linen. (Your first change of linen was soiled again before you had even finished repositioning the patient.) As you cross the hall a patient from another room yells at you, "Hey, come change my brief! I'm dirty." What do you say? At this moment, you may only be able to say, "I'm very sorry, I will come as soon as I can, I'm in the middle of changing another person right now." Though it is painful to say and goes against personal principles of quality care, it may be your only option. The patient may not be happy, but he is more likely to be satisfied if you explain that you are helping another person with a similar problem and is confident that you will come to him when you are finished. Most cognitively aware patients understand the need to finish assisting someone else in the same position and will not hold you to blame, though they remain extremely dissatisfied with the understaffed position you and they are in.

Group your work. If you have several things that need to be done in a room, take all of your supplies in at once and do as much as you can at the same time. Pass evening water with the dinner trays.

Ask family to help. While they cannot do many things, family are often able to help reposition, feed their loved one, and carry requests to staff. If the family is especially eager, they may even wish to assist with bathing or dressing. If they are willing, take them up on their offer.

Eat something. Really. It's very difficult to leave the floor when there is so much more to be done. But it will be worse if you yourself collapse from fatigue and dehydration after having eaten and drunk nothing in twelve hours. Even if it is only for a few minutes, sit down, eat a lunch, drink a glass of water, and mentally regroup and reassess the situation. You will be more effective in giving care if you care for yourself.

Don't stress over the nonessentials. It is difficult to feel satisfied with one's work when not every patient has been bathed, and needs have been left unprovided for. But in the grand scheme of things, if your patients are alive, safe, fed, are not filthy, and have stable vital signs at the end of twelve hours, you have succeeded, even if you have not been able to accomplish for them all the things that would make for optimal hospital care. Don't beat yourself up over your failure. You are human and have done what you could with what you were given. Leave this day at the unit and go home.

Don't allow yourself to become insensitive or defeatest. Report the situation to the proper authority in the chain of command even if you think it won't do any good. If the situation compromises patient safety, implement the appropriate breach of safety reporting method. Don't stop treating your patients as persons or taking their needs seriously. Callouses protect you, but not them.

Finally, pray. Your patients are God's creatures created in His image and you are His hands to care for them. He can make the impossible possible and protect you while you and them while you are at it.