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.
Sunday, February 27, 2011
Friday, November 26, 2010
The Nursing Pocket and Uniform
The most essential component of any nursing uniform is the pocket. It holds items essential for efficient function. It keeps your hands free.
I refuse to purchase a uniform for work as a nursing student, nurse aide, or nurse which does not have at least one pocket on the pants and at least two pockets on the shirt. The same goes for a jacket.
My nurse tech uniform I consider to be the best I've found yet. The pants have a deep rectangular pocket on each thigh. These are handy for keeping personal items that one wishes to keep on her; driver's license, cell phone, sanitary items, a tissue, lodge in these cavities. I don't have to worry about them all day because they won't fall out, but will be there if I need them. The shirt is a generic unisex top with a single rectangular pocket at each side. These generally hold a bandage scissors, shield skin, alcohol preps, perhaps a chloroprep or small gauze dressing. I don't put anything in these pockets that I'll be needing immediately or often, or anything that won't lie flat.
The pockets of my jacket are really my functional pockets. I work out of them.
First, a segue in defence of my jacket:
I realize that a jacket is unnecessary and in fact may be cumbersome or unrecommended in some areas of practice. Here is why I always wear one.
First, I wear it to make myself comfortable. Sleeves shield my arms from debris in the air and from the patients I have close contact with. Since my skin is often chapped and broken, I feel especially reticent to expose it directly to debris and frequent caustic cleansers. By the end of the day, my arms still feel dirty, but they feel less filthy than my face because of the slight protection afforded by sleeves. Second, I wear it for appearance. Unisex scrub tops are distinctly unbecoming. Jackets (particularly tailored designer ones) add a more professional appearance to my otherwise short, squat frame. Thirdly, jackets afford me large pockets not closely bound to my body (i.e. they don't make the shirt bulge uncomfortably). Jackets often have three or more easily accessible pockets where I can categorize and reach commonly needed materials and instruments throughout the day.
Back to pocket contents. My nurse tech scrub jacket has four pockets: two large rectangular front hip pockets and two slightly sloping pockets outside of these. In the right outer pocket I keep my notebook, in the inner pocket my pens. In the left pockets I keep my watch face and small bottle of hand-sanitizer. Also, any extra gloves end up in this pocket. These are the basics. Other things may be added as the day goes on, but this is the minimum.
Basic Pocket Supplies
Pens
Must have pens. Your day will be miserable if you don't have black pens handy to write information and chart. There will be vital signs to take and record, patient requests to relay to the proper personnel, and important info to jot for yourself.
Pocket Notebook
You must have paper of some sort to do the jotting upon. You don't have time or hands to carry a clipboard or large notebook with you. Your paper must fit in your pocket. You also don't have the luxury of a hard surface. You'll have to lay the paper on your other hand or the wall (if you can reach it). Hence, my preference is a pocket size spiral bound book of notecards. The whole thing is hard and easy to write upon. Each page is sturdy and won't tear or bleed on you. In the case of a missing I&O slip or the need to pass vital signs to a nurse, you can hang or hand a note card rather than searching for a medium.
Alcohol Preps (and Chloroprep depending on the facility)
This is not as essential for the aide or tech, but for the student or nurse to venture into the fray without alcohol preps is madness. Almost every task you will perform will require you to disinfect the area you are to work with whether it be related to an IV, and injection, a port, or a blood sugar check. Furthermore, (and here I refer especially to aide and tech work) alcohol is just about the only thing that completely removes staining from dry erase patient sign boards. During the day you may drop many things on the floor. Before returning them to the bedside table or your pocket, alcohol is indicated.
Watch
A patient's wall clock may provide sufficient orientation to time, but when vitals time comes around, you'll need a second hand that you can hold within your line of vision as you watch your patient's respirations.
Bandage Scissors
There will always be nasty stuff to cut off in nursing. Old bandages, tape, even clothing if too tight or an emergency. Clean dressings and biohazard bag covers for IV's (while showering)need to be cut out as well. You won't have time to run for scissors - you need them on you now.
Tape
In the same vein as scissors, tape is essential. In addition to the uses of tape the average person is familiar with, dressings may need to be reinforced. For this reason, I suggest cloth or paper tape at least. If possible, I recommend carrying both paper and plastic tape (for waterproof and non-skin adhesive needs)
Skin shield
If you don't use it, the nurse you're assisting probably will. It's just nice to have handy.
Gauze or Bandaids
It's nice to have gauze near to reinforce dressings or apply to exposed wounds or scrapes when needed. Also, its something your nurse may ask for.
Hand-sanitizer
When you need quick cleansing but sink and foam alike are out of reach, a personal bottle of alcohol scrub is quite convenient.
Gait Belt.
In my work, either my patients don't need a gait belt or have their own at bedside. But as I understand, in a residential nursing facility it's helpful for the aide to wear one so as to have it constantly at hand.
I refuse to purchase a uniform for work as a nursing student, nurse aide, or nurse which does not have at least one pocket on the pants and at least two pockets on the shirt. The same goes for a jacket.
My nurse tech uniform I consider to be the best I've found yet. The pants have a deep rectangular pocket on each thigh. These are handy for keeping personal items that one wishes to keep on her; driver's license, cell phone, sanitary items, a tissue, lodge in these cavities. I don't have to worry about them all day because they won't fall out, but will be there if I need them. The shirt is a generic unisex top with a single rectangular pocket at each side. These generally hold a bandage scissors, shield skin, alcohol preps, perhaps a chloroprep or small gauze dressing. I don't put anything in these pockets that I'll be needing immediately or often, or anything that won't lie flat.
The pockets of my jacket are really my functional pockets. I work out of them.
First, a segue in defence of my jacket:
I realize that a jacket is unnecessary and in fact may be cumbersome or unrecommended in some areas of practice. Here is why I always wear one.
First, I wear it to make myself comfortable. Sleeves shield my arms from debris in the air and from the patients I have close contact with. Since my skin is often chapped and broken, I feel especially reticent to expose it directly to debris and frequent caustic cleansers. By the end of the day, my arms still feel dirty, but they feel less filthy than my face because of the slight protection afforded by sleeves. Second, I wear it for appearance. Unisex scrub tops are distinctly unbecoming. Jackets (particularly tailored designer ones) add a more professional appearance to my otherwise short, squat frame. Thirdly, jackets afford me large pockets not closely bound to my body (i.e. they don't make the shirt bulge uncomfortably). Jackets often have three or more easily accessible pockets where I can categorize and reach commonly needed materials and instruments throughout the day.
Back to pocket contents. My nurse tech scrub jacket has four pockets: two large rectangular front hip pockets and two slightly sloping pockets outside of these. In the right outer pocket I keep my notebook, in the inner pocket my pens. In the left pockets I keep my watch face and small bottle of hand-sanitizer. Also, any extra gloves end up in this pocket. These are the basics. Other things may be added as the day goes on, but this is the minimum.
Basic Pocket Supplies
Pens
Must have pens. Your day will be miserable if you don't have black pens handy to write information and chart. There will be vital signs to take and record, patient requests to relay to the proper personnel, and important info to jot for yourself.
Pocket Notebook
You must have paper of some sort to do the jotting upon. You don't have time or hands to carry a clipboard or large notebook with you. Your paper must fit in your pocket. You also don't have the luxury of a hard surface. You'll have to lay the paper on your other hand or the wall (if you can reach it). Hence, my preference is a pocket size spiral bound book of notecards. The whole thing is hard and easy to write upon. Each page is sturdy and won't tear or bleed on you. In the case of a missing I&O slip or the need to pass vital signs to a nurse, you can hang or hand a note card rather than searching for a medium.
Alcohol Preps (and Chloroprep depending on the facility)
This is not as essential for the aide or tech, but for the student or nurse to venture into the fray without alcohol preps is madness. Almost every task you will perform will require you to disinfect the area you are to work with whether it be related to an IV, and injection, a port, or a blood sugar check. Furthermore, (and here I refer especially to aide and tech work) alcohol is just about the only thing that completely removes staining from dry erase patient sign boards. During the day you may drop many things on the floor. Before returning them to the bedside table or your pocket, alcohol is indicated.
Watch
A patient's wall clock may provide sufficient orientation to time, but when vitals time comes around, you'll need a second hand that you can hold within your line of vision as you watch your patient's respirations.
Bandage Scissors
There will always be nasty stuff to cut off in nursing. Old bandages, tape, even clothing if too tight or an emergency. Clean dressings and biohazard bag covers for IV's (while showering)need to be cut out as well. You won't have time to run for scissors - you need them on you now.
Tape
In the same vein as scissors, tape is essential. In addition to the uses of tape the average person is familiar with, dressings may need to be reinforced. For this reason, I suggest cloth or paper tape at least. If possible, I recommend carrying both paper and plastic tape (for waterproof and non-skin adhesive needs)
Skin shield
If you don't use it, the nurse you're assisting probably will. It's just nice to have handy.
Gauze or Bandaids
It's nice to have gauze near to reinforce dressings or apply to exposed wounds or scrapes when needed. Also, its something your nurse may ask for.
Hand-sanitizer
When you need quick cleansing but sink and foam alike are out of reach, a personal bottle of alcohol scrub is quite convenient.
Gait Belt.
In my work, either my patients don't need a gait belt or have their own at bedside. But as I understand, in a residential nursing facility it's helpful for the aide to wear one so as to have it constantly at hand.
Saturday, October 30, 2010
The Nurse Aide
I think I may safely say that the nurse aide is a linchpin in effective patient care, a linchpin that is often overlooked, underestimated, and improperly trained. I say this not because I am currently employed as an aide, but because of what I have witnessed in my work and nursing training. The properly trained nurse aide who performs his or her duties conscientiously has the closest, most intimate contact with the patient and is consequently first aware of changes in patient condition and privy to patient confidences, fears, concerns, and noncompliance.
The work of an aide may be basic, but it is foundational to any sort of medical treatment or care. The patient who receives his medications but is not bathed, turned, talked to, changed, listened to, or fed, will die. A person may have the best surgeon in the world, and the best (if overextended) nurse, but if he consistently is cared for by a lazy or incompetent aide, his body’s recovery will be poor at best, and his human soul ignored and humiliated. The measurements that an aide takes – intake and output, weight, vital signs – may be simple and routine, but accuracy is paramount. Recognition, diagnosis, treatment, and safety depend on these measurements. Doctors dose medications (and no medication is safe) based on weight, blood pressure, intake and output. Vital signs are not called “vital” for no reason. Significant changes indicate life or death crises which accurate early recognition can correct. When aides (or nurses) are sloppy, estimate, or fabricate values, they are dealing with more than merely recording a number so their shift’s work appears complete: they are jeopardizing the lives of the patients entrusted to their care and crippling the ability of the physicians to effectively treat their patients. They are working against the goals of their employing hospital.
That said, many well meaning aides do not understand the critical nature of the tasks they perform. What’s a little urine dumped down the toilet that didn’t get recorded in the strict I&O? So Mr. Smith didn’t get a bath today – he looks pretty clean. Mrs. Mega was sleeping – surely I shouldn’t have to turn her every two hours and wake her up. Mr. Chuck had a wet brief for half the morning, but he pees nearly every half hour and after all isn’t that what a diaper is for?
I cringe when I encounter scenarios like this. It’s not that the aides intend harm. It’s just that they don’t understand the rationale behind the tasks required of them. They don’t understand the ramifications of their actions for the patients’ health, and frankly, many of them don’t put themselves in their patients’ shoes. They feel sorry for their patients and are just awfully glad they aren’t where their patients are physically and mentally. Or the aides are focused on doing only what is required for their job. They do what they have to do. But patients aren’t checklists or job descriptions. Patients have unique needs that require a genuine commitment of caring in order to be discovered and met.
This brings me to the intended topic of this post: what qualities make a good aide good?
• Conscientiousness
The nurse aide must be deliberate and conscientious about the core tasks he or she performs. He needs to know which corners cannot safely be cut and commit to not cutting them. She needs to be willing to redo a poorly done task if other staff is unwilling to complete it properly.
• Empathy, Compassion, Dignity, Humanness
The nurse aide must care. She must “give a rip” about how the patient is feeling today, about the patient’s new stuffed toy, the car that he imagined he drove during the night, the kids that the demented patient is convinced she must pick up from school, the pillow that makes the patient feel uncomfortable, the particular way the patient wants his stuff arranged on the table, the fact that the patient in room 42 is offended that he didn’t get cream of rice for breakfast while the patient in room 43 insists that cream of rice is only for babies and she wants real food.
The aide must show interest in her patient’s lives, in their comfort and distresses. More than interest, she must be ready to intervene in whatever way she is occupationally able to diminish the distress associated with a hospital stay and promote fuller function while preventing further deterioration and distress.
The aide must treat his clients with dignity, even when they don’t look or act very dignified. Each of your patients is a human being with a human soul like yours, no matter how hemmed in it is by malfunctioning flesh. They can hear you and see you and feel you even if they cannot tell you. Your hands are touching the bodies they can no longer care for. Your actions and reactions can make them either feel helpless and worthless or preserve their dignity and sense of inherent worth. The aide must think about what he would wish were he in the hospital bed.
• Understanding
The good aide knows why he does what he does. She may not understand fully the physiology behind her work, but she is aware of the significance of her work and how she fits into the healthcare team. He also recognizes when he needs help. He doesn’t try to fix his client alone, but secures the appropriate help. He recognizes when what he sees in his client’s condition or vital signs requires prompt medical or nursing intervention and reports his observations immediately and appropriately.
• Priority
The good aide prioritizes care to meet patient needs. If you are an aide, chances are you have more work than you could ever accomplish during your shift. Even if you didn’t have to get specific tasks done, patient wants and requests alone would keep you busy all day. The good aide is able to organize herself so that she addresses the most pressing needs first, can accomplish the maximum amount of tasks with the minimum of trips and time, and still finds a way to satisfy as many patient requests as possible.
• Advocacy
The good aide is a patient advocate. He works the system for his patients because he knows how and they don’t. If he identifies a need, he finds a solution by contacting the appropriate personnel and watching to see that follow up is actually done. Example: it’s 1pm and your patient hasn’t had lunch yet because no tray came for him. Now you could let him be hungry, or you could call down to the kitchen and get one sent up. C’mon, it doesn’t take that long. Maybe your patient is groaning and tells you that his pain is at an 8 on a 0-10 scale and that the nurse hasn’t been in with his medicine yet. You could shrug and walk off, or you could go find the nurse, ask how soon she can bring the medicine and tell her how you found the patient. If necessary, you can keep reminding her of the patient’s need until she goes in and addresses it. Hopefully, you won’t have to, but you need to be willing to put up some polite fight for your patients if the situation calls for it.
There are plenty of other qualities that round out the good aide, but these come immediately to mind. To all aides: please cultivate these qualities in yourself. And know that you are vital to the life and health of your residents or patients. The effectiveness of the whole medical team is influenced by your care and the measurements you take. Take your work seriously – how you go about your tasks changes lives.
The work of an aide may be basic, but it is foundational to any sort of medical treatment or care. The patient who receives his medications but is not bathed, turned, talked to, changed, listened to, or fed, will die. A person may have the best surgeon in the world, and the best (if overextended) nurse, but if he consistently is cared for by a lazy or incompetent aide, his body’s recovery will be poor at best, and his human soul ignored and humiliated. The measurements that an aide takes – intake and output, weight, vital signs – may be simple and routine, but accuracy is paramount. Recognition, diagnosis, treatment, and safety depend on these measurements. Doctors dose medications (and no medication is safe) based on weight, blood pressure, intake and output. Vital signs are not called “vital” for no reason. Significant changes indicate life or death crises which accurate early recognition can correct. When aides (or nurses) are sloppy, estimate, or fabricate values, they are dealing with more than merely recording a number so their shift’s work appears complete: they are jeopardizing the lives of the patients entrusted to their care and crippling the ability of the physicians to effectively treat their patients. They are working against the goals of their employing hospital.
That said, many well meaning aides do not understand the critical nature of the tasks they perform. What’s a little urine dumped down the toilet that didn’t get recorded in the strict I&O? So Mr. Smith didn’t get a bath today – he looks pretty clean. Mrs. Mega was sleeping – surely I shouldn’t have to turn her every two hours and wake her up. Mr. Chuck had a wet brief for half the morning, but he pees nearly every half hour and after all isn’t that what a diaper is for?
I cringe when I encounter scenarios like this. It’s not that the aides intend harm. It’s just that they don’t understand the rationale behind the tasks required of them. They don’t understand the ramifications of their actions for the patients’ health, and frankly, many of them don’t put themselves in their patients’ shoes. They feel sorry for their patients and are just awfully glad they aren’t where their patients are physically and mentally. Or the aides are focused on doing only what is required for their job. They do what they have to do. But patients aren’t checklists or job descriptions. Patients have unique needs that require a genuine commitment of caring in order to be discovered and met.
This brings me to the intended topic of this post: what qualities make a good aide good?
• Conscientiousness
The nurse aide must be deliberate and conscientious about the core tasks he or she performs. He needs to know which corners cannot safely be cut and commit to not cutting them. She needs to be willing to redo a poorly done task if other staff is unwilling to complete it properly.
• Empathy, Compassion, Dignity, Humanness
The nurse aide must care. She must “give a rip” about how the patient is feeling today, about the patient’s new stuffed toy, the car that he imagined he drove during the night, the kids that the demented patient is convinced she must pick up from school, the pillow that makes the patient feel uncomfortable, the particular way the patient wants his stuff arranged on the table, the fact that the patient in room 42 is offended that he didn’t get cream of rice for breakfast while the patient in room 43 insists that cream of rice is only for babies and she wants real food.
The aide must show interest in her patient’s lives, in their comfort and distresses. More than interest, she must be ready to intervene in whatever way she is occupationally able to diminish the distress associated with a hospital stay and promote fuller function while preventing further deterioration and distress.
The aide must treat his clients with dignity, even when they don’t look or act very dignified. Each of your patients is a human being with a human soul like yours, no matter how hemmed in it is by malfunctioning flesh. They can hear you and see you and feel you even if they cannot tell you. Your hands are touching the bodies they can no longer care for. Your actions and reactions can make them either feel helpless and worthless or preserve their dignity and sense of inherent worth. The aide must think about what he would wish were he in the hospital bed.
• Understanding
The good aide knows why he does what he does. She may not understand fully the physiology behind her work, but she is aware of the significance of her work and how she fits into the healthcare team. He also recognizes when he needs help. He doesn’t try to fix his client alone, but secures the appropriate help. He recognizes when what he sees in his client’s condition or vital signs requires prompt medical or nursing intervention and reports his observations immediately and appropriately.
• Priority
The good aide prioritizes care to meet patient needs. If you are an aide, chances are you have more work than you could ever accomplish during your shift. Even if you didn’t have to get specific tasks done, patient wants and requests alone would keep you busy all day. The good aide is able to organize herself so that she addresses the most pressing needs first, can accomplish the maximum amount of tasks with the minimum of trips and time, and still finds a way to satisfy as many patient requests as possible.
• Advocacy
The good aide is a patient advocate. He works the system for his patients because he knows how and they don’t. If he identifies a need, he finds a solution by contacting the appropriate personnel and watching to see that follow up is actually done. Example: it’s 1pm and your patient hasn’t had lunch yet because no tray came for him. Now you could let him be hungry, or you could call down to the kitchen and get one sent up. C’mon, it doesn’t take that long. Maybe your patient is groaning and tells you that his pain is at an 8 on a 0-10 scale and that the nurse hasn’t been in with his medicine yet. You could shrug and walk off, or you could go find the nurse, ask how soon she can bring the medicine and tell her how you found the patient. If necessary, you can keep reminding her of the patient’s need until she goes in and addresses it. Hopefully, you won’t have to, but you need to be willing to put up some polite fight for your patients if the situation calls for it.
There are plenty of other qualities that round out the good aide, but these come immediately to mind. To all aides: please cultivate these qualities in yourself. And know that you are vital to the life and health of your residents or patients. The effectiveness of the whole medical team is influenced by your care and the measurements you take. Take your work seriously – how you go about your tasks changes lives.
Thursday, August 26, 2010
Mind Your Manners!
Everyone has a bedside manner. It's the way you act when you're in the presence of the sick. The only question is what kind of bedside manner you have: good or bad.
I think, basically, it comes down to politeness. Manners are dropped when we as healthcare professionals become focused on the tasks we have to do for our patients rather than on the patients themselves in their humanity. When we treat them as lumps of wounded flesh, or machines that are still ticking, or jobs to be done, or problems to be handled, we stop thinking in terms of politeness and respect. Manners are customs between persons, a give-and-take dance between human beings. One can defer to a machine, but one cannot be polite to it.
Sometimes we stumble over ourselves trying to meet every little need and want before the patient even knows they want it, but in the process fail to actually connect with the human being inside of the demanding, slow, sick form before us. Sadly, sometimes we don't take the time to ask permission to touch, to explain what we will do, to step out to provide privacy, to beg leave to rearrange. We march right in to manhandle, scrub, and goad, thoughtless of the dignity we trample and the boundaries we cross so forthrightly. We enter a persons most personal realm - our eyes, fingers, instruments - bore into their bodies: We demand a trust, but are we willing to build confidence? In our hurry to put their stuff in order we lay a stumbling block before the feet of the blind. Perhaps very literally.
I take as a prime example, a blind patient I've worked with. You don't really HAVE to talk to an "normal" independent patient much. You bring in the lunch tray, you set it down with a hearty, "Here's lunch! Do you need anything else?" and you walk out. When you take in 'Pete's' tray, you have to take time to "show" Pete his meal. I draw up the table and set the tray squarely in front of him. Removing the lid, I guide him through the contents.
"You have salad, yogurt, a banana, mashed potatoes, gravy, pork chops, green beans, coffee, and milk. Your plate is right in front of you. Mashed potatoes are on the left of your plate; pork chops are on the right with green beans at the top. Here's your coffee. See it?" I ask as he touches the cup with his fingers and places it where he wants it. ('Pete' refers to his touch as "seeing") "Here's your yogurt and spoon." I've learned that it is easiest for Pete if I hand him his yogurt so he can set it where he wants it and find it without putting his fingers in it. "Your milk is behind your coffee and your banana is above your plate. Fork is on the left and knife and spoon are on the right."
Now, I could plop the tray in front of Pete and run, leaving him to messily "see" what is there for himself. I could rattle off the above explanation and split. But good manners demand that I stay until I'm certain that Pete has successfully "seen" his tray and knows where he is and what is happening. Good manners demand that I do this in a respectful manner, as one would give a guided museum tour to a party of professors, rather than as one would explain simple kitchen chores to a child.
The saddest instance in caring for Pete came the day Pete was turned around. He was getting a room-mate and the nurse had rearranged the room. He was in his wheelchair and had somehow been turned without realizing it as well. He asked me to bring him something from the table to the right of him, not realizing it was actually behind him, and to help him get into bed, not realizing he was trying to get into his room-mate's (unoccupied) bed feet first. He's a smart man, fully intellectually competent, but his world had been rearranged. It annoyed me that it hadn't dawned on the nurse that Pete couldn't actually function if he couldn't "see" his room and his stuff. He could have potentially panicked trying to find the door at the opposite side of the room. I brushed off the nurse's fluttering, and Pete and I discussed the location of his environment, beginning with the his orientation in the room (front, back, window, door, bed) and ending with the exact location and contents of all his drawers, tables, and belongings.
Yes, I chafe when I think that while I wait, nine other patient's trays are cooling on the cart. Yes, I itch with the urge to hasten and be on with other tasks unnumbered and unknown. But before me sits a person who needs to see. The choice is not whether I will care for his body, but whether I will treat him as a fellow. It is a question of whether or not my humanity and his humanity will find each other. As a patient his humanity is exposed. His hand lies passively open and waiting. It is mine to put my hand in his.
When we're through he tells me, "You know, you're not too bad. No matter what they may say, you're not bad."
I think he means to say that I met him as a person. He's returning the compliment.
I think, basically, it comes down to politeness. Manners are dropped when we as healthcare professionals become focused on the tasks we have to do for our patients rather than on the patients themselves in their humanity. When we treat them as lumps of wounded flesh, or machines that are still ticking, or jobs to be done, or problems to be handled, we stop thinking in terms of politeness and respect. Manners are customs between persons, a give-and-take dance between human beings. One can defer to a machine, but one cannot be polite to it.
Sometimes we stumble over ourselves trying to meet every little need and want before the patient even knows they want it, but in the process fail to actually connect with the human being inside of the demanding, slow, sick form before us. Sadly, sometimes we don't take the time to ask permission to touch, to explain what we will do, to step out to provide privacy, to beg leave to rearrange. We march right in to manhandle, scrub, and goad, thoughtless of the dignity we trample and the boundaries we cross so forthrightly. We enter a persons most personal realm - our eyes, fingers, instruments - bore into their bodies: We demand a trust, but are we willing to build confidence? In our hurry to put their stuff in order we lay a stumbling block before the feet of the blind. Perhaps very literally.
I take as a prime example, a blind patient I've worked with. You don't really HAVE to talk to an "normal" independent patient much. You bring in the lunch tray, you set it down with a hearty, "Here's lunch! Do you need anything else?" and you walk out. When you take in 'Pete's' tray, you have to take time to "show" Pete his meal. I draw up the table and set the tray squarely in front of him. Removing the lid, I guide him through the contents.
"You have salad, yogurt, a banana, mashed potatoes, gravy, pork chops, green beans, coffee, and milk. Your plate is right in front of you. Mashed potatoes are on the left of your plate; pork chops are on the right with green beans at the top. Here's your coffee. See it?" I ask as he touches the cup with his fingers and places it where he wants it. ('Pete' refers to his touch as "seeing") "Here's your yogurt and spoon." I've learned that it is easiest for Pete if I hand him his yogurt so he can set it where he wants it and find it without putting his fingers in it. "Your milk is behind your coffee and your banana is above your plate. Fork is on the left and knife and spoon are on the right."
Now, I could plop the tray in front of Pete and run, leaving him to messily "see" what is there for himself. I could rattle off the above explanation and split. But good manners demand that I stay until I'm certain that Pete has successfully "seen" his tray and knows where he is and what is happening. Good manners demand that I do this in a respectful manner, as one would give a guided museum tour to a party of professors, rather than as one would explain simple kitchen chores to a child.
The saddest instance in caring for Pete came the day Pete was turned around. He was getting a room-mate and the nurse had rearranged the room. He was in his wheelchair and had somehow been turned without realizing it as well. He asked me to bring him something from the table to the right of him, not realizing it was actually behind him, and to help him get into bed, not realizing he was trying to get into his room-mate's (unoccupied) bed feet first. He's a smart man, fully intellectually competent, but his world had been rearranged. It annoyed me that it hadn't dawned on the nurse that Pete couldn't actually function if he couldn't "see" his room and his stuff. He could have potentially panicked trying to find the door at the opposite side of the room. I brushed off the nurse's fluttering, and Pete and I discussed the location of his environment, beginning with the his orientation in the room (front, back, window, door, bed) and ending with the exact location and contents of all his drawers, tables, and belongings.
Yes, I chafe when I think that while I wait, nine other patient's trays are cooling on the cart. Yes, I itch with the urge to hasten and be on with other tasks unnumbered and unknown. But before me sits a person who needs to see. The choice is not whether I will care for his body, but whether I will treat him as a fellow. It is a question of whether or not my humanity and his humanity will find each other. As a patient his humanity is exposed. His hand lies passively open and waiting. It is mine to put my hand in his.
When we're through he tells me, "You know, you're not too bad. No matter what they may say, you're not bad."
I think he means to say that I met him as a person. He's returning the compliment.
Wednesday, August 25, 2010
Bedside Manners
What on earth do I need another blog for? Nothing, really. I'm starting this blog as a place to record thoughts from clinical practice, as distinct from the rest of my online life as my life at the hospital is distinct from my casual existence. I hope to be able to share experiences and insights into patient care in a generalized way that does not breach privacy or confidentiality. Maybe, this exercise will help me learn some more manners along the way. That's it for tonight.
The first rule of preparing for good patient care is to rest yourself beforehand. So off to sleep with me!
The first rule of preparing for good patient care is to rest yourself beforehand. So off to sleep with me!
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