The Dark Side of Nursing

In the spirit of learning through social media, I’m inspired to follow up on Dr. Eric Levi’s post on The Dark Side of Doctoring.

In case you haven’t read about it, it is regarding a physician who committed suicide. It is about how something is wrong with the basis of our healthcare system. It’s about how nearly 1 in 12 people who go into healthcare — to help people — end up needing help themselves because of our system. Our system continues to fail us because we push people to — and then beyond — their limits.

It is not simple enough to say, take a mindful minute.

It is not simple enough to say, just take a break or two.

It is not simple enough to say, get the help you need. Because even when we are surrounded by the resources that we need, we still fail. People often see a healthcare provider within 30 days before committing suicide.

We are in a culture where it is expected to be short staffed. We are in a culture where it is expected to:

  • squeeze each healthcare provider —
  • do something a specific way dictated by people who have never taken care of patients before,
  • refuse to discuss changes to an OR schedule because it’s mandated by the administration,
  • take call and expect to be a fully functioning person the next day.

It is one thing to be resilient. It is another thing to damage the human spirit.

One of the worst experiences in my career started at the beginning. I was a brand new nurse working at the nursing home/rehabilitation center. The LPN (licensed practical nurse) who worked there for years, knew her residents, knew the medications that the residents received. But one day, she called in sick. Of course, that meant I had to give all of the medications. 50 residents. 6 with PEG tubes. In 2 hours.

It takes at least 5 minutes to verify the resident’s name, the medications in the paper copy of the medication records AND the electronic medical record, give the medication, wait for them to swallow. Nevermind that medications still needed to be popped into the cup. Nevermind that I had to find each resident (because they do move around). And the patients with PEG tubes often require more time to crush and dilute. And don’t forget that when the tubes get clogged that it took additional time to rinse.

5 minutes x 50 residents = 250 minutes. Yeah, I was on a path to failure.

By the time I finished giving the morning medications, it was already time for noon or afternoon medications to be given. I didn’t go on break (no one was there to relieve me). I didn’t eat lunch. I didn’t have any support. I cried that day. Shortly after that, I never went back again. I was lucky enough to quit.

I couldn’t deliver quality nursing care. I felt that I could lose my shiny new license. I knew it wasn’t the right way and I knew I didn’t want to practice this way. I didn’t have any support.

And this situation doesn’t just apply to me. It applies to nearly every nurse giving medications. Giving the appropriate amount of time for each nurse to talk to their patients regarding their medications, their medical condition, and spending time with them when their loved ones aren’t around is vital. Giving each nurse the appropriate patient to nurse ratio is so vital.

The appropriate patient to nurse ratio gives the nurse more time, effort, and energy to take care of each patient. There needs to be more time

  • to provide nursing care,
  • to educate,
  • to prevent medication errors, infections, falls, deaths,
  • to question, coordinate and provide treatments,
  • to monitor the patients’ status,
  • to be the patients’ advocate, and
  • to be a resource for patients, their families, and other healthcare providers.

Michigan is currently pushing for a Safe Patient Care Act to decrease the patient to nurse ratio. If we want to reduce readmissions, preventable deaths, and provide safe and quality care, then we should pass this act. There have been multiple studies that prove this to be true. We need to care more about patients than the bottom line.

Changing Culture

The healthcare culture needs to change. To take care of others, we must take care of ourselves. But we cannot take care of ourselves if the culture does not allow us to do so.

We value being a hardworking person. That’s why we say it’s ok to do overtime, then being on call, then being at work the next day. That’s why we work way over 40 hours a week — pushing 60-80 hour workweeks.

We value being helpful. We want to help patients, and if we don’t do overtime, then we would be abandoning patients.

We value money. That’s why hospital administrators short staff the hospital and push up their profits.

These are our primary drivers. Instead, we should shift our fundamental values to:

Healthcare providers’ health.

  1. Valuing the healthcare providers’ health should be one of the most important values in healthcare. We are people and require a work-life balance (including students, interns, and learners of all type). We need time to be human, time be with friends and family, time to eat, exercise, and sleep. We need time when we aren’t thinking about healthcare and can destress.
  2. Depression and substance abuse is, unfortunately, high among healthcare providers. In media, we have an image of a drug addict. But healthcare providers have access to high potency drugs and can easily and quickly abuse substances. Addiction can hide behind a mask, a suit, and highly intelligent, functional people. A couple of weekends ago, I attended the Michigan Association of Nurse Anesthetists Spring Conference, and one of the topics was on addiction. It was eye opening. This was one of my favorite videos on addiction.
  3. If being on call is required, that they should be off the next day. Or there should be a rotation system so that you are not constantly called every night.
  4. That every effort will be made not to be short staffed.
  5. That working 40 hours a week — and not much more — is the norm.
  6. That means giving people adequate vacation time, paternal/maternal leave, and not making people feel bad about it or making it hard to take time off.
  7. That means giving 2 15 minute breaks and a 30-minute lunch for every healthcare provider for a 8 hour day (this does not happen on a medical-surgical unit, let alone over a 12 hour day).
  8. That means providing in-house educational opportunities.
  9. That means encouraging healthcare providers to do or implement research.

Patient’s health.

All of us have been a part of the healthcare system and therefore should care about this tremendously. A huge part of the problem is communication errors. Now instead of a scarcity of information, we have an abundance. We need to have a streamlined process. Electronic medical records (EMR) is a part of the solution, but there are still problems. Often, the EMR technicians have never worked in healthcare and are the ones putting together these systems. Instead of a single page where there is the patient’s history, treatments, labs, diagnostic reports., information is scattered. It requires going through several different tabs and is very time-consuming. And even then, it is still easy to miss information.

Instead of being focused on coding for such and such, it should be about improving the patient’s health. Giving enough time and energy for each patient will improve the patient’s health. Sitting down, understanding each patient’s situation, and developing a course of action together. We need to focus on patients’ health, and not on patients’ paperwork.

Healthcare providers’ input.

To improve healthcare, it requires input from those in the trenches. It does not make sense to ask outside consultants who have no healthcare experience to improve healthcare. Yes, this does happen frequently. And these consultants are expensive. Why are we so focused on making healthcare into a business model rather than a patient care model? Instead, we should ask the providers themselves on what they think needs to change.

Price Transparency.

What blew my mind the other day was reading an article about how parents who were worried about their daughter’s cut took her to the emergency room. The emergency physician said it was a nothing to worry about and put a bandaid on and sent them home. A month later the bill comes out to be $626 for a band-aid. It happened to be that there’s a facility fee for emergency rooms. But it is still ridiculous. Most people (especially those not in health care) need help triaging, or deciding how bad their condition is. When you’re the one in pain, it is always the worst thing that’s happening to you.

Part of the this problem is the blaming game. The doctors blame the insurance companies. The insurance companies blame the doctors and their coding. The patients blame the doctors, the insurance companies, the greedy hospitals and the government. I think what would help solve this problem is transparency about the cost of care. There’s a disconnect between the cost of healthcare and the services provided. For example, most people have no idea how much it costs to stay in the ICU for one day. Most people have no idea how much it costs to do one elective surgery. Sure, it’d be nice to call up the insurance companies and ask them but they come back and say, it depends on what your doctor bills. You ask your doctor and they say it depends on how much the insurance bills you. For the same exact surgery, the insurance will bill differently at each hospital (even surrounding a 50 mile radius). The cost of healthcare is just way too high because there’s no way to ‘shop’ for healthcare or healthcare insurance like you can with other services.

Transparency, or having a sticker price up front, would help patients decide where to go. In fact, there are already some places that often a total knee replacement for $15,499 that covers everything — the surgery, the rehabilitation, and any complications that occur afterward. Price transparency encourages facilities to provide high-quality care and decrease costs while still earning profits.

 


So I would like to ask, what is the ‘dark side’ of nursing for you? What do you think can change? Please comment below.

Career Day

Last week, I had the opportunity to represent as a CRNA student at a middle school. In my preparation, I found a few inspiring talks about how to choose a career.  I remember when I was in 6th grade, on my way home from swim practice, I broke down crying and asked my dad, “what’s the purpose of my life?” In retrospect, that was deep.

Anyways, Ashley Stahl, a career coach, said you should ask yourself three questions to choose a fulfilling career. This, hopefully, is a key factor for happiness.

  1. Who am I?
  2. What am I good at?
  3. What’s holding me back?

In detail:

Who am I?

This question requires you to think about the most important values in your life. Everyone is unique in that they hold varying values more closely. Family, friends, the media, etc. can all affect your perception of what is most important to you. Ultimately, choosing the ones that matter to you the most is what will help you live your life the way you want. Values will determine your behavior and attitude and guide your life.

Remember, other people’s values can pull you away from yourself. ‘Lists’ of how to be happy don’t often work. However, living out your values will make you happy. While some people value family time, others may value individualism and climb the career ladder. Others may value both. This can cause an internal struggle, or it’s possible to create or find an organization that allows you to live out both values. Others may value education, etc. It is helpful to find a career and organization that most aligns with your values. Of course, some values may change over the course of your life, depending on the stage in your life.

Personally, I value education, optimism, caring, persistence, kindness, and traveling. I’m sure several of these values were pressed into me. Taking care of my education is number one because no one can take that away from me. Always trying to beat my personal best. It’s a competition with myself to push me to do better than the last time. And to reflect, what did I do well? What can I improve on?

When I don’t feel right, it’s because I’m not living out one of my values enough. When one value is lacking, it’s time to nurture it. It may be difficult to do if a value depends on others. For example, if you value being the best, and now you’re in school again (such as anesthesia school), and you’re back at the bottom of the food chain (in the OR), it will feel very uncomfortable. Either you shift your values (which can be difficult to do but a change in perception can help significantly), or you continue to struggle until school is over and you’re practicing on your own.

What am I good at?

This was one question that was hard for me to know, especially when I was younger. I expected everyone to be just as good as me in everything. Of course, this is not true. Ashley suggested that you can find your strengths by someone TAPping you… Teach, Advice, Praise. What are others asking you to teach them? What are others asking you for advice in? What do others praise you in?

Of course, you will realize that you cannot be good at everything and that you can improve your skills through practice, through visualization, through discussions. Tune in your natural abilities.

But how do you know? Through experience. My mom has always told me that any experience is a good experience (except drugs. Thanks for the advice). Anything that may pique your interest (or a part time job that will hire you) try it out. I recommend reading www.80000hours.org. It’s called 80,000 hours because that is the time you will spend in a career.

What’s holding me back?

Other people’s values and expectations of you will hold you back. Your fear of failing. Your internal talk saying, “I’m not good enough” or “I don’t belong here” or “I’m an imposter”. Yup, I’m guilty of this too. Several times throughout school I would question my ability. Do I belong here? To get myself out of this feeling, I used my value in optimism to take me out of the funk. “Jess, you are learning. You will make mistakes. Don’t be so hard on yourself. What can you do next time so you improve?”

When you are in a new situation, visualize the scenario. I remember my first semester of school when I arrived in the OR at 5:30 am to set up my room. It was certainly exhausting. How do I check out my machine? Which syringe size do I need for each drug? Where are the drugs? How much drug should I draw up, should I use? Which colored label belongs to each drug? Why aren’t all the blue ones, orange ones, white ones bunched together??! Where is all of the equipment, and which drawer? I physically walked from the door to the head of the bed and thought through my steps. Later, I had to think, how will I prone a patient? I physically held out my hands and pretended to move the patient’s head from supine to prone. Of course, later on I realized that I also had to be aware of all of my monitors and lines too.  The next time, I was considerate of my lines. The next time after that, I became more and more aware of my surroundings and different cues.

What helps is having a clinical instructor, a mentor, a boss, a friend, an acquaintance, who can listen, see, and understand what you’re going through and guide you through those difficulties. What are failures they’ve encountered that would make it easier for you?

There are days when you’re harder on yourself, and days when a ‘superior’ – be that an instructor, or a senior, or someone up the hierarchy in some way – will tear you down. One day is usually ok. But when it’s a constant uphill battle, it can be difficult to mentally withstand it. From being in school where there’s an evaluation of your work everyday, I’ve come to appreciate resilience.

I remember playing Final Fantasy and as one of the stats was resilience. I thought, WHO CARES about resiliency? I want strength! However, now I believe that the ability to pick yourself up after being knocked down is so vitally important. What is your coping mechanism? Some turn to drugs, some turn to family time, some will need to vent to classmates, some need therapy, some will dive in deeper in their studies, etc. Ideally, don’t do drugs because you’ll go down a rabbit hole that may be hard to get out (of course, rehab is an option but if at all possible, you can avoid it, why not?). How can you pass the daily evaluations?

Daily evaluations can be tough because one bad one can lead you out of the program. The fear of failing out of the program is real. Getting into anesthesia school is a big ordeal for yourself and your family and friends. It’s almost ‘everything you stand for.’ Failing out can be detrimental not just for yourself but from those closest to you. For example, there’s a story about an anesthesia student who failed out and then committed suicide on the day of her ‘supposed’ graduation. Very scary!!) However, ultimately, it is about what your choices and how you deal with each situation. For me, I have plan A, B, C. Of course, I want plan A but if that fails, plan B kicks into place. For me, having a backup plan (a backup anesthesia plan and life plan!) was a sense of calm that I needed to reassure myself that I can do it.

 

Long time, no see

Hi readers of Nurse Jess,

It has been nearly a year since I posted on my blog. Some readers (aka a few junior anesthesia students) have met me and wondered if I’ve fallen off. Nope, I am right here!

Every time I considered posting, an exam, a care plan, paper, or even the limited time off to do nothing, pulled me away. But now I’m back.

I have so much to say and yet so little time to do it. I could write a lot, as I often do, to convey all of my thoughts. But I will try to keep it short to encourage me to post more.

Since the beginning, I’ve done over 700 cases and over 1800 clinical hours. And there’s still 4.5 months left of anesthesia school. It may seem like a lot, or a little, depending on who you are.

That time doesn’t include class days, the preparation for clinical, the preparation for anesthesia school (GRE, CCRN), the intensive care unit hours, the bachelor of science in nursing AND biology. In my mind, it’s been ten years of training. Wow.

I have to admit, the beginning of anesthesia school was tough. What makes the training challenging is at first, you are learning the basics of airway management (intubation, LMA, oral and nasal airway, chin-lift, jaw-thrust, etc.) and the anesthesia flow for each type of surgery and unique to each patient (preoperative, intraoperative, postoperative course). Not only that, but each anesthesia provider (CRNA and anesthesiologist) have their preferences and expectations of you. Even during the short breaks, one CRNA may be ok with your choice, but another CRNA would reprimand the choice. The only thing you can do is to understand their choice (What’s the rationale?). As they say, there are a 1000 ways to skin a cat.

Now, there’s less anxiety and more of a discussion, even as I go to different clinical sites. It’s much easier to anticipate changes and adapt to the circumstance. For example, just today there was a switch in the schedule. Last year, I felt more frantic and had to think about my each step more carefully (especially in pediatric cases when there’s a change in age and weight that require a change in equipment size and drugs). Today, it changed from a two-year-old, 15kg to a 6-year-old, 25kg for ear tubes (*real age and weight are changed). What are the appropriate emergency drug doses I would give? What equipment changes do I need to make? I switched a size 3 to a size 4 mask, and had a 5.5 ETT (endotracheal tube or breathing tube) with a MAC2 blade, and thought –

  • atropine 0.02mg/kg = 0.5mg = 1.25ml,
  • succinylcholine 4mg/kg IM = 100mg = 5ml,
  • epinephrine (1:10,000 or 0.1mg/ml or the big stick) 0.01mg/kg = 0.25mg = 2.5ml.

Anyways, that’s it for today.

Jess

#100Intubations

Anesthesia school is a 2-year marathon.

When you feel tired and beat up, you just have to keep going. Just keep going to clinical.

Anyways, I just wanted to announce a couple of things.

First, I’m done with my second semester and I’m onto my third semester. I took a week off for a family vacation in between the semester. It was definitely much needed. This semester is supposedly better in some ways. For example, there are less OR jitters compared to the 1st semester. But going to a new clinical site presents its own challenges (a new anesthesia machine, new charting system, different drug dispensing, different protocols, different equipment, different labels, different drug vials and doses, new names and faces, not knowing where anything is, new surgeons, new procedures, different patient population, etc). Now we’re going strong by going to clinical 4 days a week and 1 day of class (and my, that day is 10 hours long!!). When I look back at what I knew in October versus now, it is a huge difference. It’s incredible.

This semester there’s a couple of focuses: research, emergency management, regional anesthesia. I’m pretty pumped. I’ve come far but there’s still much more to go. Resiliency has never been more important than now.

Second, as of yesterday, I’ve done 100 successful intubations. It’s a great feeling.

Third, thanks to everyone who’s been writing me positive messages about the blog, supporting me through the flashcard purchases, and anyone who’s enjoyed reading my blog. I see that each month there are more visitors and visits than the next, despite me not updating it as frequently as I used to.

Fourth, happy nurses week again.

Fifth, congrats to those who got into the UM-Flint nurse anesthesia program. It was nice meeting some of you and I’m sure we’ll meet again soon enough!

I have to go now. Until next time,

Jessica

Michigan vs MSU

All this week, there’s been so much hype about the Michigan vs MSU. With Coach Jim Harbargh at Michigan, Michigan football is doing better than ever. Usually, I don’t really follow but my fiancé is a huge fan (he listens to podcasts and even submits questions via Twitter, haha) and now I’m a student!!

Anyways, Michigan has been dominating the last 4 games although MSU has won all five games undefeated thus far.

Apparently people all over the country are driving or flying in, staying in the cheapest hotel almost 30 minutes area at $250, with the cheapest tickets going at $175 this year (unless you’re a student who got season tickets).

Guy Fiori is going to be at Meijers this morning. “Game Day” is happening at the Diag. Somehow my friend talked me into going so I woke up early to get some studying done before I take a morning break and start back up in the afternoon.

It’s gonna be a lot of fun.

Speaking of studying, there’s a lot of new material. There’s a final exam in physical assessment and a principles exam coming up on pediatrics, fluid and electrolytes, blood products, and part I of the anesthesia workstation (yes, I can draw the oxygen molecule from the hospital outside, through the entire machine, and to the patient circuit— wow!).

I definitely feel on edge at a much higher rate than ever before. I’m usually a pretty calm person but now more than ever, I can feel my heart racing and getting anxious. And that’s almost everyday. I try to calm my nerves by either studying more, or setting time aside to go for a walk or watch some funny TV. Taking care of myself is probably one of the most important things I can do to endure through the program.

I learned this week (amongst other things), that a “sugar high” isn’t really a sugar high. As a tasty candy bar, full of “simple sugars” or glucose or monosaccharides readily available for insulin to act on, glucose is too quickly shoved into cells, causing a hypoglycemic effect. The alpha cells in the pancreas senses the hypoglycemia and releases glucagon. Epinephrine is also released from nerve endings and adrenals. Both glucagon and epinephrine go to the liver, which then undergoes glycogenolysis, breaking down glucagon into glucose and releasing it back to the bloodstream.

However, image the little kid full of epinephrine, setting off the sympathetic nervous system, causing him to run around like crazy during recess or banging his head against the wall. So a “sugar high” is really caused by “hypoglycemia” that’s induced by our more primitive insulin that floods our bloodstream when sensing a huge amount of glucose. If instead the ingested glucose was complex such as a starch, then our insulin is a much better match, releasing the appropriate amount of insulin without going overboard.

I did a few spinals this week (how cool and amazing it is!!) but next week I will try to do more general cases. All right, enough updating. Until next time.

Jessica

PS. I know the first round of interviews is coming up so I just want to say good luck to anyone who’s interviewing at UM.

PSS. The double rainbow outside my window on Thursday is the featured photo. Nature is beautiful.

Clinical starts 

The last day of simulation was on Friday (can you believe that it’s been a month since I started?) and clinical starts this week! I’m excited and nervous.

First week of exams are over. Now we just have 1 exam each week until the end of December. 

The things we learned this week:

  • Proteins
  • Pediatric overview
  • Second gas effects

What I learned in clinical:

  • Propofol can burn, especially when the IV is in the hand or forearm. Unless contraindicated, give the lidocaine!
  • Don’t tell them that it won’t burn. Because it just might. 
  • Make sure the IV is working pre-op.
  • Always be ready to change location on the fly and be prepared for general anesthesia when doing a monitored anesthesia care (MAC) case.
  • Have all the drugs looked up, patient history, and be able to discuss the plan with the CRNA. 
  • Follow through with what you say. 
  • Be confident with your preoperative  assessment. Hit all the major points. Make sure you know their anesthetic history. 

Ok, here it goes. 

Also, the super moon lunar eclipse was cool. Though I may only feel this way because I’m not working today. Usually on a full moon, it gets just a little crazier in the hospital. I’m not sure if it’s just a coincidence.  

Here’s the supermoon with the eclipse starting. 

  

 

At 10:15pm EST, the moon turns blood orange. So cool! What a beautiful night. 

#NursesUnite

This week was interesting. I remember first seeing this video 6 days ago with all this positivity about a Miss America contestant, Kelley Johnson, talking about her experience as a nurse. I thought that was such a different take on what it means to have a talent. It’s not the typical talent showcased on Miss America  so I was actually glad that nursing was explained as a talent.

Then, The View happened. Although I don’t think that Joy and Michelle, the talk show hosts, went out of their way to make fun of nurses, they were simply ignorant of what nurses do. Nonetheless, it was hurtful to hear that Miss Colorado was just “reading her emails”, wearing a nurses “costume” and was questioned why she was wearing a “doctor’s stethoscope,” which really is just a stethoscope.

However, I can see how the hosts could be misled. As a relatively healthy person who hasn’t muddled in the healthcare field, you may see the nurse get a set of vital signs, ask for a history, and maybe give shots. You may not really see the difference a nurse makes in that scenario. Instead, you’ll see physicians who will use their “doctor’s stethoscope” to listen to you.
It’s only once you’re sick in the hospital that you see the nurses work their magic. I know that was what got me hooked. The compassion, skill, listening abilities, tough love attitudes… I knew I had to be one.
Regardless, Facebook blew up with #nursesunite and the group “Show Me Your Stethoscope” grew over 600,000 members in a couple days. Memes popped up all over and everyone in the healthcare team supported nurses. It was an amazing outrage.
doctor's stethoscope and nurse's costome
And here’s another:
nursesunite
And another:
insult nurses
 But this post is my favorite:
nursesunite
nurses unite
On Wednesday, The View attempted to apologize, but it was a half apology where they blamed the nurses for not listening to the content. Except that nurses are actually really great listeners and know that is not how you apologize. You have you owe up to your mistake and not blame others. People were still not satisfied with the response.

During this time, Johnson and Johnson and England’s Best decided to pull their advertising from The View. Considering how much J&J supports nurses, I actually appreciate that effort.
On Thursday, The View and NYU decided to have an educational segment about the role of nurses. Rather than playing the blame game, it’s better to educate.
 socrates the secrete of change

On Friday, the segment focused where nurses are and have made a difference. The NYU Stimulation instructors explained more broadly about what nurses do and described the educational background required for a nurse but I wished it was a bit more personal where they describe a more complex story that involved a nurse who played various roles and how they lead care. This would open people’s eyes into what nurses do.

You don’t really know what nurses do until you’re under their care. You’ll see providers come and go, but your nurse will be there for you. They will explain to you what’s going on when things get scary, work to allay fears, give medications, help you do almost anything that you can’t do, push you to do better, teach you about your medications and how you may have to change your life, make sure you’re safe from any kind of errors, act as your PT, OT, RT, speech therapist, and so much more. But you won’t even know they do all those things until you need them.

nurses do a lot

Michelle and Joy genuinely seemed interested and did seem to feel remorse for what happened. Raven, however, looked really bored who did not talk. It would’ve been better if she had engaged with her body to at least seem interested.
raven
Before the end of the segment, stethoscopes were given out. I thought that was unnecessary because, as Joy shortly demonstrated after receiving one, she and other lay people do not know how to use one. Stethoscopes are an important medical tool, not a gift given to those who don’t know how to use one.
At the end, NYU recruited some of their nurses and nursing students (because I recognized those purple scrubs) to come out and support the educational segment.
Even if this is done as a publicity stunt to bring back the primarily audience to watch the show, I’m glad The View did it. At least they addressed the source of concern and hopefully they realize that you cannot just say anything and expect that people will accept it.
Ignorance is not always bliss.
It was amazing to see this kind of outpour of support and willingness unite on this. I hope that, despite our need for instant gratification for a desired effect, that nurses can unite on other things just as strongly.

Week 3: First Official Week 

Flexibility. Even in the first week, not everything went according to plan. But it’s about the willingness to adapt and go with the flow. 

The things I learned this week:

  • The Larynx — the cartilages, ligaments, muscles, and how all of those things work together and affected by anesthesia. And what are likely problems that can occur and how to respond. 
  • OR — checking the anesthesia machine and table top set up. 

This coming week is the first full week of class so here it goes!