Archive for the ‘Nursing perspective’ Category

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More Than Competencies and Checklists: The Shadow Side of Nurse Orientation

March 30, 2015

‘Developing beneficial working relationships is part of a successful nursing orientation. If you’re lucky, your preceptor is explaining the nuances.’

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog. The illustration below is hers.

Paradisi_Illustration_ShadowI led the first patient I had contact with as a nurse navigator to the hospital restrooms—this was her most pressing concern at the time. Building on this success, I now have a small number of patients to navigate through their cancer journeys, under advisement of my preceptors.

During this early stage, I’ve become aware that, running parallel to my orientation, a shadow orientation is also occurring.

This umbral orientation doesn’t come, like its more tangible counterpart, with a sheath of paperwork with competencies to perform or checklists to mark off. But it’s just as real. Awareness of shadow orientation develops on an intuitive level. While this experience is difficult to describe in words, it feels familiar.

Shadow orientations happen to everyone. Nearly 30 years and several nursing jobs since that first one, I’m acutely aware of the importance of a good first impression. Fortunately, this particular orientation of mine is going smoothly, but here are some observations based on past experiences.

Shadow orientation is present when you meet a staff member who makes it known this is her desk, her chair, her phone—maybe not in words, but with a look and a click of her tongue as she makes a great show of finding somewhere else to sit, despite your offer to give up the seat.

It’s happening when a physician won’t speak to you directly about your patient, instead giving his orders to the charge nurse, because you’re new. When you question it, she explains, “It takes him a long time to trust new nurses.” But she does nothing to facilitate an introduction between you.

Another example: There’s much discussion about working relationships between nurses and physicians, but little is said about the interactions between nurses and ancillary staff, such as respiratory therapists, X-ray technicians, phlebotomists, or unit secretaries. Each play important roles in patient care, but negotiating workflow can be a source of friction, depending on the individual’s level of professionalism.

I’m only partially joking when I advise striving for a good working relationship with the unit secretary. She or he knows who to call for a vacant bed, the phone and fax numbers you need, and how to make the office machines work. Even now, I can manage a patient safely on a ventilator, but am nearly helpless when the copier machine doesn’t work.

Developing beneficial working relationships is part of a successful nursing orientation. If you’re lucky, your preceptor is explaining the nuances. Read the rest of this entry ?

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AJN in April: Deep Breathing for Dialysis Patients, Isolation Care, Sleep Loss in Nurses, More

March 27, 2015

AJN0415.Cover.OnlineOn our cover this month is Pablo Picasso’s Le Rêve (The Dream). We chose this portrait of a woman in a restful pose to highlight the importance of proper sleep to a person’s overall health and well-being. Unfortunately, not many Americans are able to get the proper amount of rest. The Institute of Medicine (IOM) estimates that 50 to 70 million U.S. adults have chronic sleep and wakefulness disorders—and nurses are not immune.

Between long shifts and the stressful nature of their jobs, nurses are especially vulnerable to not getting an adequate amount of quality sleep. Fatigue from lack of sleep may diminish the quality of nursing care. Sleep loss has been linked to impaired learning, memory, and judgment and is also associated with a slew of chronic diseases. This month’s CE feature, “The Potential Effects of Sleep Loss on a Nurse’s Health,” describes the acute and chronic effects of sleep loss on nurses, strategies nurses can use to improve the quality of their sleep, and institutional policies that can promote good rest and recuperation.

This feature offers 2 CE credits to those who take the test that follows the article. You can further explore this topic by listening to a podcast interview with the author (this and other free podcasts are accessible via the Behind the Article podcasts page on our Web site, in our iPad app, or on iTunes).

Deep breathing for dialysis patients. Chronic kidney disease (CKD) generally has a poor prognosis and often causes poor sleep quality, reduced quality of life, and is associated with high rates of hospitalization. It’s no surprise that an estimated 25%–50% of patients with CKD suffer from depression. This month’s original research CE, “The Efficacy of a Nurse-Led Breathing Training Program in Reducing Depressive Symptoms in Patients on Hemodialysis: A Randomized Controlled Trial,” examines the efficacy of a nurse-led breathing training program in reducing depression and improving quality of sleep in patients on maintenance hemodialysis. This feature article offers 2.5 CE credits to those who take the test that follows the article. Read the rest of this entry ?

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Interprofessional Collaboration and Education: Making an Ideal a Reality

March 25, 2015
Photo courtesty of Penn Medicine.

Photo courtesty of Penn Medicine.

We hear a lot about interprofessional collaboration, the potentially dynamic and enlightening process of sharing knowledge across disciplines to improve patient care, but what’s being done to make this a reality?

The promotion of interprofessional collaboration is one focus of an ongoing national initiative by the Future of Nursing: Campaign for Action, as described in “Interprofessional Collaboration and Education,” an article in the March issue of AJN.

To close the gap between policy bullet points and the reality of daily work for nurses is neither impossible nor inevitable; it depends on smaller coalitions and the engagement of multiple organizations—but also, one imagines, a willingness to engage in inquiry and to try new and imperfect processes at the local level that may need refinement over time. The article is free, but here are a couple of paragraphs that give an a good overview of why it matters and where we are:

Interprofessional collaboration is based on the premise that when providers and patients communicate and consider each other’s unique perspective, they can better address the multiple factors that influence the health of individuals, families, and communities. No one provider can do all of this alone.

However, shifting the culture of health care away from the “silo” system, in which clinicians operate independently of one another, and toward collaboration has been attempted before without enduring success. For nearly five decades a commitment to interprofessional learning has waxed and waned in health professions training programs. During this time, health care leaders have shown intermittent interest in interprofessional collaboration in the delivery of health care. Strong and convincing outcome data demonstrating the value of team-based care have been lacking, but changes in our health care system now require that we explore how we can make interprofessional collaboration the norm instead of the exception.

Read the rest of this entry ?

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Missed Empathy, Missed Care: Is It Time to ‘Reconceptualize Efficiency’?

March 23, 2015

A physician’s lament is nursing’s, too.

By Maureen Shawn Kennedy, AJN editor-in-chief

By Alan Cleaver/via Flickr

By Alan Cleaver/via Flickr

Last week, the New York Times Well blog published “The Importance of Sitting With Patients” by Dhruv Khullar, a Harvard medical resident. Khullar expressed regret over not spending more time with a patient who was near death, and then discussed how little time residents actually spend with patients—eight minutes, according to a Journal of General Internal Medicine study (2013) that analyzed the time of 29 interns over a month. (The study found that only 12% of the residents’ time was spent on direct patient care; 40% of their time was spent on computers.)

Khullar detailed the various activities that take him away from direct patient contact and noted as well that the shorter working hours mandated for residents had the unintended consequence of reducing time with patients. He wondered:

By squeezing the same clinical and administrative work into fewer hours, do we inadvertently encourage completion of activities essential in the operational sense at the expense of activities essential in the human sense?

The second part of the question seemed especially pertinent for nurses. Hospital nurses have long lamented that paperwork, insufficient staffing, and nonnursing tasks keep them from the bedside. The promise of computers to reduce documentation time has yet to be realized, as first-generation documentation systems are not necessarily designed from a nursing perspective and often lack the specificity and flexibility to truly capture nursing activities. Read the rest of this entry ?

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Workplace Conflict Engagement for Nurses: Consider the System

March 20, 2015

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

by Sachin Sandhu/Flickr

by Sachin Sandhu/Flickr

This month, Debra Gerardi writes about initial steps to managing workplace conflict as nurses. The quotes below are from her article in the March issue of AJN, “Conflict Engagement: A New Model for Nurses” (free until April 30, the article is one in an ongoing series on conflict).

Just as with most medical errors, there is usually not a single cause of workplace conflict—instead, a number of interrelated variables lead up to an event.

Sure, I was new to nursing, but I wasn’t new to work. My life as the child of small business owners had ingrained in me a certain sense of duty that I felt my colleague lacked. When you grow up with parents who make you pick up cigarette butts in their business parking lots, no work is below you, and there’s no time to complain. Maya wasn’t new to nursing, but she seemed, to me, new to the idea that work was to be done without a fight.

In my first months on the unit, I saw her complain much more than I saw her put her head down and plod through the tasks before her. Our unit was full of really sick patients, to be sure, and glitches like overflowing trash or equipment holdups too often set us back, forcing us to tend to jobs meant for others. But instead of voicing my frustration, I bit my lip and took on every task I came upon, judging my colleague for her unwillingness to silently do the same.

Maya and I soon clashed, probably because she picked up on the disapproval that I wore on my face. While I never told her that I interpreted her opposition to our daily workplace setbacks as laziness, our mutual frustration with each other became palpable. It never occurred to me to try to tell her how I felt; I had no desire to engage Maya in finding a solution. To me, she was the problem.

Effectively addressing conflict in complex systems requires an understanding of how systems function, and ultimately a shift in thinking toward a systems view of organizations.

One day, after a lunch room volley that publicly exposed our simmering conflict, Maya angrily pulled me into an empty patient room. My words to the group eating with us had implied that Maya was to blame for a slip-up, and although the incident hadn’t affected patient care, I’d made my feelings about her work ethic evident to all.

What Maya said to me that day shifted my narrow view of our conflict into one that encompassed our entire system, and changed my view of nursing work forever:

“It is clear we don’t like each other. We don’t need to like each other. We do, for the sake of our patients, need to respect each other. It’s dangerous to them if we don’t.” Read the rest of this entry ?

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