Archive for November, 2011

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On Protocols, Shortcuts, and the Unforgettable Smell of Ether

November 9, 2011

By Linda Johanson, EdD, RN, associate professor of nursing at Appalachian State University, Boone, NC

In nursing school my professors warned us of the dangers of taking shortcuts when performing procedures. They cautioned that deviations from protocols could lead to serious error. I had to learn this lesson the hard way, and although it’s been about 30 years since I made this mistake, I still remember the occasion like it happened yesterday.

The patient was in ICU bed #10, a glassed-in isolation room across from the nursing station. He was in his mid-60s, but he was mentally handicapped, so he appeared and acted younger. He was in the unit recovering from a respiratory arrest, and on the day I was caring for him he was still intubated, but breathing spontaneously.

by james bowe, via flickr

I was completing an assessment on him when the charge nurse called to me from the nursing station, and I stuck my head out the door to see what she wanted. She told me there was a new order to remove the patient’s indwelling urinary catheter. I checked my pockets for a 10 mL syringe to perform the procedure but didn’t find one.

When I complained about having to go all the way to the supply room to collect one, the charge nurse queried, “Well, you have scissors, don’t you? You can just cut the catheter with them. The balloon will deflate, and it will pull right out. I’ve done it a hundred times.”

Cut the catheter? I had never heard of that before, but I was a relatively new nurse, so I hadn’t been exposed to a lot of things yet. Of course I had scissors right in my pocket, and I got them out. Was this an example of one of those unacceptable shortcuts we’d been warned about in nursing school? It would sure be quicker and easier than running all the way to the supply room.

I approached the patient, who although unable to comprehend what was happening, seemed to regard me with a trusting expression. I exposed the catheter and opened my scissors to a spot about one inch from its point of entry. I hesitated for one brief second, then snipped the tube. I gave the catheter a little tug, and the patient winced. The tube stayed firmly in place, the balloon obviously fully inflated. Read the rest of this entry ?

Posted in nursing perspective | Tagged , , , , , , | 8 Comments »

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Realizations of a New Nurse #1: I Am Now the Educator

November 7, 2011
image via Wikipedia

By Kinsey Morgan, RN. Kinsey is a new nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA.

In nursing school, there is a growing push to educate future nurses on the amazing breadth of roles within the nursing profession. As a student, you are in some way exposed to the role of nurse as leader, advocate, healer, educator, team player, and researcher. Even this list is not exhaustive. These roles are certainly vital and important and worth teaching about in school.

As a brand new nurse, I haven’t personally encountered all of these roles yet, but there is one in particular that I encounter—and embody—every day: that of educator.

One of the most humbling realizations I’ve had since recently becoming a nurse is that I am now the educator. I’m glad to know that there are other nurses around me, as well as many resources from which to glean knowledge, but I am daily faced with the fact that people now look to me for answers. There are times when I feel outside myself, for while I give correct answers, hearing myself giving them is a little surreal. I’m sure these feelings subside with time, but I hope that I always remain somewhat in awe of the amount of trust my title elicits.

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Posted in nursing perspective, nursing students, professional identity | Tagged , , , , | 4 Comments »

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Staff Nurses at the Center: Joyce C. Clifford’s Still Radical Notion

November 4, 2011

By Katheren Koehn, MA, RN, who is a member of the AJN editorial board

It was with great regret that I read of the passing of Joyce C. Clifford last week. She was a nurse whose career as a nurse administrator and leader was spent empowering nurses, from the bedside to the boardroom. Much has been written since her passing about her nursing leadership at the administrative level. I would like to take some time to recognize her as a nurse leader who empowered nurses at the bedside.

I first learned of the work of Joyce C. Clifford from a staff nurse who’d moved from Boston to Minneapolis in the late 1980s. The entire time this nurse and I worked together she was in mourning for the hospital and job she’d left behind in Boston. Almost every day she talked about how wonderful Beth Israel was and how great it had been to be a staff nurse there. She talked about primary nursing, nurse autonomy, and interdisciplinary respect. At the time, none of these terms were familiar to me, but I knew she was telling me that “my” hospital, where she now worked, could never measure up to the fabulous BI.

I next learned of the work of Dr. Clifford through the book Code Green: Money-Driven Hospitals and the Dismantling of Nursing by Dana Beth Weinberg. In this book, Ms. Weinberg described the nursing environment that had been created under Dr. Clifford’s leadership:

When Beth Israel Hospital adopted primary nursing on its inpatient floors in the 1970s, the hospital also adopted a host of new organizational arrangements. The architects of Beth Israel’s professional nursing practice argued that by meeting nurses’ needs, the hospital simultaneously met those of patients. Beth Israel organized itself around nurses’ work, supporting and encouraging the work that nurses did with patients.

Organizing a hospital around nurses’ work, encouraging the work that nurses did with patients! Those are sweet words to a staff nurse’s ears. No wonder my nurse colleague was mourning the job she’d left when she moved to Minneapolis! Read the rest of this entry ?

Posted in nursing innovations, nursing perspective, patient perspective, professional identity | Tagged , , , , | 6 Comments »

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In Defense of On-the-Job Learning in the ICU

November 2, 2011

Image via Wikimedia Commons

By Marcy Phipps, RN, who is a regular contributor to this blog. She emphasizes that the identity of the impatient practitioner described in this post has been altered in significant ways to prevent any chance of recognition.

“This is why new nurses have no place in critical care!” said the trauma physician. “I’m sure she’s a fine nurse, but she should be getting experience with these situations on the floor!”

The issue of whether new nurses should work in critical care comes up from time to time. It seems to polarize people, and it always touches a nerve with me. I was hired directly into the ICU upon passing the boards, as were many of the nurses I work with. My hospital offers a program to new graduates that includes training and education specific to critical care and an extended clinical experience with a preceptor. Admittedly, there is a steep learning curve, but I wouldn’t consider it unsafe—and comments that suggest the contrary irritate me, because they undermine new nurses and foster negativity.

This patient probably would have pulled his PEG tube out no matter how experienced his nurse was, and I’m not sure the step-down floor would have been a “better” place for a new nurse to manage that situation. The patient acuity is lower on the floor, but there are also fewer nurses around to help out, and a patient would probably have more opportunities to pull a PEG tube out, assuming that was his intention, given the more private nature of the rooms. These things do happen occasionally, regardless of the precautions taken, and I don’t know any nurse who wouldn’t have been at least a little flustered, no matter where they were. I certainly would have been.

The new nurse came back the next night and had the same patient assignment. She was composed and professional, and it occurs to me that the trauma physician was right about one thing—she is a fine nurse. And she’ll get better all the time, here in the critical care unit, where she’s losing her “fluster” and thickening her skin, despite the glare of a doctor who doesn’t think she should be here in the first place.

*PEG = percutaneous endoscopic gastrostomy

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Posted in nursing students, professional identity | Tagged , , , , | 6 Comments »

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