Archive for the ‘patient perspective’ Category

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Good Jokes, Bad Jokes: The Ethics of Nurses’ Use of Humor

April 29, 2015

By Douglas P. Olsen, PhD, RN, associate professor, Michigan State University College of Nursing in East Lansing, associate editor of Nursing Ethics, and a contributing editor of AJN, where he regularly writes about ethical issues in nursing.

Humor has real benefits. But when does nurses’ joking about patients, each other, and the care they provide cross a line?

Photo from otisarchives4, via Flickr.

otisarchives4/Flickr

“Nurses make fun of their dying patients. That’s okay.” That was the provocative title of an op-ed by Alexandra Robbins in the Washington Post on April 16. The author’s treatment of the topic was more complex than the title suggested, but some examples of humor given in the article were troubling.

For ethical practice, nurses must consider if it is ever appropriate to discuss the clinical care of patients for humorous purposes. An easy answer would be—never. If patient care is never joked about, then no one’s feelings are ever hurt and nothing inappropriate is said as a joke. However, my experience as a nurse in psychiatric emergency and with human nature suggests two arguments against this approach:

  • Jokes will be made despite any prohibition.
  • Considerable good comes from such humor.

If jokes are going to be told anyway, it’s better to provide an ethical framework than to turn a blind eye. If joking about patient care is sometimes acceptable and sometimes not, nurses’ jokes are more likely to stay ethical if they consider in advance under what conditions it’s ethical to joke and how one distinguishes ethical from unethical humor.

According to Vaillant (1992), humor is among the most mature of the defenses. “Like hope, humor permits one to bear and yet to focus upon what is too terrible to be borne” (Vaillant, 1977). Those who have experienced the stress of intense clinical practice know the value of finding humor in life’s tragedies. In addition, patients who are able to cope with their physical and emotional pain are often those who find the humor in tragedy.

Still, some attempts to make people laugh are unkind, and it hurts to be the subject of others’ laughter. Vaillant distinguishes humor from wit, noting that humor never excludes (1977). It may help nurses to enjoy the beneficial effects of humor and avoid the effects of harmful humor if we attempt to identify some characteristics of appropriate humor. Watson (2011) offers some useful suggestions for self-examination to determine the acceptability of clinical humor:

  • Is the joke about the patient, the situation, or the clinicians themselves?
  • Does the joke reveal disdain or contempt for the patient?
  • Could the joke affect care? An example might be jokes suggesting that a patient deserves pain or disability. Wear et al. (2006) demonstrated that medical students treated patients considered responsible for their pathology as “fair game” for derogatory humor. And nurses have more difficulty empathizing with patients they consider responsible for their pathology (Olsen, 1997). Therefore, jokes enhancing this perception could erode a nurse’s relationship with that patient.
  • What is the underlying intent of the joke—is the motive to influence clinician behavior or attitude? This includes both harmful and helpful intent. Some jokes could be used to gently chide a clinician toward more empathy. Upon hearing a nurse refer to drug-seeking patients in a derogatory tone, I may retort, “Of course they’re lying about their pain. What would happen if she told the triage nurse that she has a five-bag-a-day habit and her dealer is out of town?” The comment generally gets a laugh, and my goal is to give the nurse a chance to consider the patient’s perspective and perhaps see the situation less as despicable deception and more as the desperation of unmet needs.
  • Is it true humor—that is, is it inclusive, a clever juxtaposition, insightful—or is it simply mean-spirited mockery of another’s misfortune? This distinction is subtle and is often dependent on personal intuitive reaction: Does it feel cruel, callous or uncaring? Do you feel shame at saying or hearing it? Does laughing at the joke make you uncomfortable? These reactions vary widely, as can be seen in the public debate regarding what is called “political correctness.”

Filter yourself when thinking to tell a joke and reacting to another’s humor. Pause a moment before telling the joke or reacting to another’s comment; let your intuition and values weigh in. Then, speak—or don’t.

A more difficult ethical issue is whether it is acceptable to make potentially hurtful jokes if one can reasonably ensure that the joke remains within the clinical circle. Read the rest of this entry ?

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The Challenge of Eating Disorders: A Teacher Learns a New Mindfulness Technique

April 27, 2015

“She’s brought a cup with her. This is not unusual. Clients often bring food or drinks they’re required to finish—but when Mariko reaches inside the cup, I hear the brittle clicking of ice and look closer. There’s no beverage. She pulls out a piece of ice and, without a word, curls up on her side, cradling the cube tenderly in her palm.”

By Jacob Molyneux, senior editor

Illustration by Anne Horst for AJN.

Illustration by Anne Horst for AJN.

We hear a lot lately about mindfulness and its benefits in the workplace for dealing with stress, increasing productivity, and the like.

It’s been pointed out lately that mindfulness has become a tool with many uses, some more in keeping with its role in various spiritual traditions than others. Such traditions seem to use meditation practices in order to cultivate compassionate awareness of the varieties of suffering arising from the impermanence of everything from pleasant and unpleasant feelings and the weather to the lives of our loved ones.

This month’s Reflections essay in AJN is by a mindful movement teacher at an eating disorder treatment center. Eating disorders can involve mental and physical suffering that’s unrelenting and self-sustaining. Many clinicians and therapists find patients with eating disorders very challenging to work with. The essay, called “Distress Tolerance,” tells the story of an encounter in which the patient teaches the teacher a surprising new mindfulness technique. Here’s the opening:

How are you?” Asking this question always feels ridiculous, especially with someone undergoing eating disorder treatment, but I say it automatically.

“Average,” Mariko responds quietly, tucking a strand of limp, jet-black hair behind her ear as she bends to select a yoga mat and two pillows.

“Average” is code for something much worse. Though she is in group treatment, it’s just us today. Her group tends to be small—and volatile. I blink in surprise as she chooses her spot, unrolling her mat quite close to mine.

Read the rest of this entry ?

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A Nurse Ethicist’s Analysis of a Recent Nursing Home Sexual Consent Case

April 21, 2015

By Douglas P. Olsen, PhD, RN, associate professor, Michigan State University College of Nursing in East Lansing, associate editor of Nursing Ethics, and a contributing editor of AJN, where he regularly writes about ethical issues in nursing.

scales of justice/by waferboard, via Flickr

scales of justice/by waferboard, via Flickr

An 78-year-old retired state legislator and farmer in Iowa is currently on trial for having sex with his wife, who has severe Alzheimer’s disease, in her shared room in a nursing home. He has been charged with rape.

The case highlights two ethical questions or conflicts:

  • When is protection needed and when is it intrusive and harmful?
  • What are the mental abilities required to consent to sex?

Consenting to sex is not the same as informed consent for treatment. In treatment, a clinician obtains consent to act on (treat) the patient in a way that will benefit the patient. By contrast, proper consent for sex is mutual and both parties benefit.

To extend the comparison: a patient’s decision to consent to treatment is generally made by balancing the benefits, harms, and risks to the individual patient. The decision to engage in sex often involves consideration of another’s satisfaction—it is not unknown for one spouse to agree to sex to please the other, even though he or she would not otherwise want sexual contact.

Another complicating factor in the question of sexual consent is that gender matters. While the social ideal is to consider sex consensual, societal understanding often tilts toward considering the male as the aggressor and the female as the gatekeeper. In addition, we often assume that power, especially physical power, is not equal in sexual relations.

Decision-making capacity. A patient must have decision-making capacity to give valid consent for treatment. Such capacity is not considered a blanket characteristic, but is assessed in relation to the risks, benefits, and complexity of the specific treatment decision.

The assessment of capacity in relation to the specific decision can also be applied to consent for sex. Unfortunately, a proper level of mental ability needed to confer capacity for sex is not clearly established and can vary in relation to circumstances. The woman in this case had severe mental impairment, but that does not necessarily mean that she lacked the capacity to consent to sex with her husband. Differences of opinion regarding the level needed for her valid consent are illustrated in the following summary of an exchange from the trial included in a recent New York Times article:

Mr. Yunek [the defense attorney] asked Dr. Brady [the center’s physician] if “Donna is happy to see Henry — hugs, smiles, they hold hands, they talk — would that indicate that she is in fact capable at that point of understanding the affection with Henry?” Dr. Brady said no, calling that a “primal response” not indicative of the ability to make informed decisions.

The defense attorney is implying that her actions indicate desire and willingness and that this is a sufficient level of mental ability for valid consent; the physician, on the other hand, suggests that such “primal responses” are not sufficient to indicate a level of mental ability. This is not a disagreement about what her ability is, but about what is the proper degree and type of ability needed to consent. It’s not so much a disagreement about facts as about values.

One approach to establishing whether sexual contact between these two older adults was appropriate is to examine each relevant factor. These include the following: Read the rest of this entry ?

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Morgellons: Whatever the Cause, the Suffering Is Real

April 2, 2015
Image, magnified 60 times, depicts fiber-embedded skin removed from a facial lesion of a 3-year-old boy who the Morgellons Research Foundation says has Morgellons.

Image, provided by Morgellons Research Foundation to AJN in 2008, described as depicting fiber-embedded skin removed from facial lesion of 3-year-old boy with Morgellons (magnified 60x).

By Jacob Molyneux, senior editor

As you may have read, Joni Mitchell was recently found unconscious in her home and is now in the hospital. She has attributed her health issues to a syndrome called Morgellons—a condition in which sufferers experience what they describe as fibers emerging from their skin, along with intense itching, sores that won’t heal, and a host of nonspecific symptoms such as fatigue and concentration problems.

Whether it’s a clinically verifiable illness or, as some have argued, a manifestation of a psychological condition known as “delusional parasitosis,” Morgellons is plenty real to those who experience it.

We covered this controversial illness several years back in an article called “AKA ‘Morgellons.'” I interviewed two nurses and several others about their experiences. One of the nurses (see this sidebar) was convinced she had caught the condition from a patient. I also spoke with Michele Pearson, MD, the lead investigator of a then-pending CDC study to look into the disease, which had been announced in response to an extensive patient advocacy campaign. As she put it at the time:

“It’s a complex condition . . . It may be multifactorial. What we now know is through self-report or anecdotal. There’s nothing systematic.”

Read the rest of this entry ?

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Early Localized Prostate Cancer: Nurses Can Help Men Weigh Diagnostic, Treatment Options

March 18, 2015

By Jacob Molyneux, AJN senior editor

A new diagnosis of prostate cancer can be daunting. Nurses play an increasingly important role in helping men and their partners find their way through the maze of available information and choices. One of the two March CE feature articles in AJN, “Early Localized Prostate Cancer,” gives a thorough overview of tests and treatments.

The author, Anne Katz, is a certified sexuality counselor at CancerCare Manitoba, a clinical nurse specialist at the Manitoba Prostate Centre, and a faculty member in the College of Nursing at the University of Manitoba, Winnipeg, Canada, and Athabasca University, Alberta, Canada. She is also the editor of Oncology Nursing Forum. Writes Katz:

. . . as many as 233,000 men in the United States are diagnosed with prostate cancer each year, 60% of whom are ages 65 or older. Most diagnoses are low grade and localized . . . . Since low-grade, localized prostate cancer is slow growing and rarely lethal, even in the absence of intervention, it can be difficult for men to make treatment decisions after diagnosis—particularly if they do not understand the nuanced pathology results they receive and the potential for treatment to result in long-term adverse effects that can profoundly affect quality of life.

Pros_Cons_PSA_ScreeningThe article discusses options for intervention, potential adverse effects associated with each option, and, crucially, the nurse’s “role in helping men and their partners navigate the challenges of making treatment decisions that are appropriate in their particular circumstances.”

Read the rest of this entry ?

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Telling the Truth, Keeping a Patient’s Trust

March 9, 2015

“Am I going to be okay?” Ami gasps. Her breath hitches, her chest rising and falling in spasms. One of my hands holds a mask to her face; the other hand holds hers. Pain has made her strong—my fingers are almost as white as her pale face, radiant with fear.

Illustration by McClain Moore for AJN.

Illustration by McClain Moore for AJN.

That’s the start of the Reflections essay in AJN‘s February issue, “Am I Going to Be Okay?” Nurses tell patients ‘it’s going to be okay’ because the words can keep them calm, because no one can tell the future, because it’s comforting to hear ritualized phrases from a caregiver—even when they’re not, strictly speaking, true.

But are there times when more honesty is desirable? The author of this short Reflections essay delves into one such situation where the patient needs, above all, to feel trust for her nurse. Read the rest of this entry ?

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Strong Nurse and Patient Voices On the Blogs This Week

February 20, 2015

By Jacob Molyneux, senior editor/blog editor

Photo by mezone, via Flickr.

Photo by mezone, via Flickr.

Here’s a short Friday list of recent smart, honest, informative blog posts by nurses, as well as a couple of interesting patient perspectives on prominent types of chronic illness and the ways they are talked about by the rest of us.

At Head Nurse, in “Yes…No. I’m Having Some Thoughts About BSNs,” an ADN-prepared nurse makes some familiar and some more surprising observations about the effects of the new policy of hiring mostly BSN-prepared nurses at her facility as it tries for Magnet status. For example, one of the effects she notes is “a massive drop-off in terms of the diversity of our nursing staff.” The move toward BSNs is obviously the trend in nursing, and is supported by research, but this doesn’t mean that there aren’t still two sides to the issue, or real unintended consequences to address as this change is gradually implemented.

At Hospice Diary, the blog of hospice nurse Amy Getter, there’s a post called “Hearts, Flowers, and Bucket Lists.” Reflecting on the imminent death of a patient, the author puts the popular notion of bucket lists into perspective:

“I think about some of the things I would still like to do in my life, and realize . . . . most of those wish-list items would be swept away in a moment, if I only had a little time this week. I would hug my kids harder and love more, and want to squeeze every last drop of time to put into my relationships that I will have to leave behind. “

Staying with the end-of-life theme for a moment longer, you’ll find at Pallimed, a very good hospice and palliative medicine blog, a new post with a to-do list that some of us or our loved ones really can’t put off until next month or next year: “10 Practical Things to Do When Diagnosed With a Serious Illness.”

Two consistently good nurse bloggers, both of whom have written for this blog or for the journal itself from time to time, happen to have reviews of books about aspects of nursing on their blogs this week. Read the rest of this entry ?

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