Archive for the ‘patient perspective’ Category

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Magnet Hospitals: It’s About the Process, Not the Designation

January 23, 2012

By Shawn Kennedy, AJN editor-in-chief

When I had a recent medical emergency, I went to the local community hospital near my home in northern New Jersey. I had been there before for outpatient testing or to the ER with a child and found the care attentive and efficient and the staff friendly and professional. Besides, it was a Magnet-designated hospital, so I was confident that I’d receive good care.

The ancillary staff was wonderful, but I found myself disappointed with the nurses on the acute med/surg unit where I was located. There was no rounding that I was aware of, and they seemed to only show up when it was time to administer meds. Only a few nurses introduced themselves, and only two nurses over three days really engaged me in any conversation. Nurses seemed to respond to call lights only for those patients to whom they were assigned. The unit clerk who promptly answered the call light intercom would say, “I’ll let your nurse know and she’ll be in soon”—when I asked for pain medication, she told me “your nurse is giving report; I’ll let her know when she’s finished.” I waited uncomfortably for more than half an hour.

There were whiteboards, but often the information—especially regarding the date and the name of the nurse—was unchanged from day to day and no longer accurate. (This was annoying, in that they kept asking me what date it was and I kept getting it wrong!)

The worst, though, was the noise level at night. I’ve worked nights, and I know it’s easy to forget to keep conversations hushed. But this unit was a good example of those that are as “noisy as chainsaws” (see our recent post on this). I was two doors down from the nurses’ station and I could hear every conversation, people singing holiday carols, detailed discussions of patients (forget HIPAA!). Requests that they reduce the noise made no difference. One night, I learned every detail about one nurse’s vacation plans while she and a colleague spoke in normal, conversational tones, occasionally laughing, while providing care to the elderly woman in the bed next to me at 2:30 am.

When I asked if they could speak a bit more quietly, one of the nurses angrily pulled back the curtain and told me that I had to understand that they needed to take care of the woman and would be done shortly. She then resumed talking about her vacation. I barely slept at all the three days I was there. It was exhausting, and I was happy to get home.

A few days later, I was admitted to a large teaching medical center in Manhattan, where I stayed for 10 days. The contrast was startling. The ICU nurses were incredibly attentive and supportive; they made me and my family feel that I was safe and in excellent hands. On the med/surg unit, the nurse manager introduced herself when I arrived. My assigned nurse for each shift would introduce herself and ask me if I needed anything; she came by frequently, even if only to poke her head in the room and say, “Everything OK?” Nursing assistants likewise introduced themselves and would inquire if I needed anything. Read the rest of this entry ?

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Poll: What Can We Actually Do About Hospital Room Noise?

January 17, 2012
By ArtsieApsie, via Flickr

Fierce Healthcare reports this week on the latest findings about hospital room noise: ”hospital rooms can be as noisy as chainsaws, according to a new study [subscription required] published this week in the Archives of Internal Medicine….The average noise level in patient rooms was close to 50 decibels….The noise disruptions mostly come from staff conversation, roommates, alarms, intercoms and pagers….Loud hospital rooms are associated with clinically significant sleep loss among patients and even may hinder recovery.”

So, nurses (and patients, MDs, others): can anything be done about this? Does your hospital do anything? Take our poll, and also of course feel free to leave a comment on this post.—JM, senior editor


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Those Who Wait: Recent Work in ‘Art of Nursing’

December 19, 2011

By Sylvia Foley, AJN senior editor

Beach Stone Found by mscaprikell, via Flickr

“I held that stone / in my hand for hours while they split your bones,” says the narrator of Janet Parkinson’s poem “Talisman,” which appears this month in Art of Nursing. The poem speaks to the tremendous strain of waiting for the outcome of a loved one’s emergency surgery. It’s about the  need for connection over great distances, for a “stone constant” in the face of grave uncertainty. The poet’s voice is unsentimental and steady, and the poem, just seven lines, itself feels almost talismanic. (Art of Nursing is always free online—just click through to the PDF file.)

In Roger Davies’s poem “Preparing to Pretend to Knit at the Chemotherapy Clinic,” featured in October’s Art of Nursing, a husband also waits, feeling helpless. “I’ll choose the long, elegant needles,” he says, imagining homespun wools dyed in autumn colors. Recalling his mother’s “nonchalant / competence” at the craft, he longs for the solace found in knowing what to do—even if it’s only how to hold the needles. In the poem’s last lines, the narrator says, “I could look out the window / to this fading autumn day.” But it’s clear that he’s not quite ready to see that view yet.

The Waiting Room: Norma, copyright 2010 Rebecca Thomas

Rebecca Thomas’s painting “The Waiting Room: Norma,” featured in November, depicts the artist’s grandmother, who gazes out at us, her expression both yearning and fierce. She seems to lean forward slightly into a blurred foreground, much as one might lean into an unknown future. About her grandmother, Thomas writes:  “She lived through lymphoma. Her husband didn’t. Now, the cancer and my grandfather are gone from everywhere but her face in this moment—her ‘waiting face,’ right before the smile.”

We invite you to pause with these works for a few minutes and listen for what resonates within you. And if you’re interested in submitting your own work to Art of Nursing—we consider visual art, “flash” fiction, and poetry—email me for guidelines: sylvia[dot]foley[at]wolterskluwer.com.

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Reading Between the Whiteboard Lines in the ICU

December 15, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

My hospital uses dry-erase whiteboards as a tool to communicate with patients and family members. Mounted to the walls in the patients’ rooms, the boards are prominent and concise.  Aside from a lot of basic information, notes get added to the board when diagnostic tests are completed, when complementary therapies have been implemented, and when housekeeping staff visit. The “meat” of the board, however, is the section that addresses plans and goals for the day. The plans and goals are updated and modified continuously by nursing staff. They’re specific to each patient, yet, despite their personalization, the goals for ICU patients tend to fall into distinct categories.

The first category includes goals which are often set by the patients themselves. They tend to require a certain amount of collaboration and active participation. These types of goals, which include things like “maximize incentive spirometer use,” “ambulate,” and “advance diet,” imply a relatively healthy state and tend to predict transfer orders.

The next type of goal is aimed at restoring health and stability. These goals don’t necessarily require patient participation and often focus on pathophysiologic processes. On the whiteboards of these rooms, the listed goals are likely to include things like “wean ventilator,” “control agitation,” “control fever,” or “increase level of consciousness.” In these cases, the goals are often of more interest to the family members than the patients.

The most critically ill and unstable patients are the hardest people for whom to establish goals, and sometimes the immediacy and focus required to support these patients preclude the time required to formulate and write goals on a dry-erase board. The more pressing the needs of the patient, the briefer the goals tend to be, and the brevity often portends the gravity of the situation: “oxygenate,” “ventilate,” “perfuse.” The goal “live” also belongs to this category, although decorum discourages writing “live” as the plan for the day.

Overall, the whiteboards are excellent communication tools. Although they’re not always utilized or appreciated by the ICU patients themselves, they often serve as touchstones for family members, who take comfort in written updates and established goals. They provide a different kind of communication to the nurses, though. In a unit where stability can be as fleeting as a dry-erase marker, the whiteboards sometimes provide a snapshot of general direction—especially for those reading between the lines.

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Health Care Work and Hypochondria: When Knowledge Equals Fear

December 14, 2011

Photo by Morrissey, via Flickr

By Amy M. Collins, associate editor

This Thursday I will graduate. Not from college—sadly, that was many years ago. Rather, I will finish a health anxiety class, taken in desperation when untimely hypochondria struck. I admit it. I’ve always been a bit of a worrier when it comes to health and illness. Working as a health care writer/editor doesn’t always help. I just have too much information at my fingertips, and a brain that jumps to the extreme (a pain in the side can mean cancer, and so on).

Before getting a degree in writing and journalism, I studied human biology with the intention of going into some type of health care work. But reading about diseases made me start to self-diagnose with fervor, so I decided to switch majors. And this was before the advent of the Internet, where one can constantly consult “Dr. Google.”

Years ago, while working at a medical publishing company in Spain, things got worse. I was put on the cardiovascular beat, which only increased my health fears. Diagnosed with mitral valve prolapse as a child, and on medication for arrhythmia at the time, reading about this particular disease made my heart literally flutter. My boss, recognizing my discomfort, took me off the topic and asked me to instead write about prostate cancer, benign prostatic hyperplasia, and erectile dysfunction—all conditions I could never get myself. Read the rest of this entry ?

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‘A Passing Shadow’: The Abiding Uncertainty of Cancer Survivorship

December 5, 2011

My husband and I wake into the narrow December dark. He brushes his teeth, dresses, then busies himself as I eat breakfast. His packed suitcase sits by the back door. It’s 5 AM, two days before Thanksgiving. At precisely 9 AM, the surgeon will remove my husband’s right kidney, the one he is 99% sure is cancerous.

That’s the start of “A Passing Shadow,” the December Reflections column in AJN. Written by Gail Lukasik, a poet and the author of several literary mysteries, this hopeful but tonally nuanced piece vividly evokes the uncertainty that all cancer survivors and their loved ones must live with. Click the link or the image above to read it in entirety.—JM, senior editor

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Thanksgiving in the ICU: Woven into the Tapestry of Traditions

November 22, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

cranberries

I’ll be working this Thanksgiving. I’ve worked so many Thanksgivings that the ICU feels woven into the tapestry of my own traditions. I don’t really mind; the cafeteria serves a fitting feast that’s embellished by the homemade treats we bring in, and although we won’t actually be watching it, the Macy’s parade will be on. Somehow, the smells and sounds I associate with the holiday will mix and mingle with the usual bustle of critical care, and it’ll feel like Thanksgiving. It’s actually a nice day to be at the hospital—for the nurses, that is.

For our patients and their families, I know hospital holidays fall far short. We have one patient, in particular, who’s been with us for a while. Her husband’s been a fixture at her side throughout her stay, and I expect to find him stationed there this Thanksgiving. Hospital turkey and television won’t give him the comfort or peace that he seeks, and I don’t know that he’ll be giving thanks. For many weeks I’ve watched him skirt a fine line between gratitude and despair; things could always be worse, but they could certainly be better.

When I stop to count my blessings, I’m overwhelmed. I belong to a profession that I’m passionate about—one that brings me great joy. I work with people I care about and like so much that I look forward to spending a holiday with them. And at the end of the day I’ll be going home, where my family will be waiting for me, and I’ll hug my kids and count my blessings all over again.

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Editor’s note—some AJN Thanksgiving posts from past years:

Brief Notes on Thankfulness (and the Nursing Profession)

Turkey, Sweet Potatoes, and Living Wills

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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 ?

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Toward a Less Painful Death: ICD Deactivation at End of Life

October 14, 2011

By Sylvia Foley, AJN senior editor

A few years ago, in a letter to the editor of another journal, an NP described how one of her patients, a man on home hospice care, had suffered 33 shocks as he lay dying in his wife’s arms. The source of those shocks, his implantable cardioverter-defibrillator (ICD), reportedly “got so hot that it burned through his skin.” The device that had been implanted to save his life caused this man and his wife great distress in his final hours. Device deactivation at the end of life is an option; but in this case, apparently, it had never been discussed.

Stories like this one helped to inspire the research reported in this month’s CE feature, “Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes,” by James Russo.

Lightning by snowpeak, via Flickr

ICDs, standard treatment for people at risk for life-threatening cardiac arrhythmias, work to restore normal rhythm by delivering a high-energy, painful electrical shock. The devices are so effective that people with ICDs often die from causes other than heart disease. But once a person with an ICD begins actively dying, as in the case above, the device may cause needless pain and prolonged suffering. So it’s essential for providers and patients to talk about the possibility of deactivation, well in advance of such crises.

Russo, the coordinator of the pacemaker clinic at the Department of Veterans Affairs Medical Center in New York City, wanted to better understand why providers and patients weren’t discussing this possibility and to find ways to promote more timely discussions. Read the rest of this entry ?

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Nurses and Patient-Centered Research

October 13, 2011

By Shawn Kennedy, editor-in-chief

I’m immersed in nursing research and nursing leaders this week, attending (in order and immediately following one another) meetings of the Council for the Advancement of Nursing Science (CANS), the 25th anniversary concluding scientific symposium of the National Institute of Nursing Research (NINR), and finally, the American Academy of Nursing.

Wednesday was CANS and its focus on comparative effectiveness research. After an opening keynote by Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), who discussed the need to accelerate progress in improving U.S. health outcomes, a panel of nurses discussed different methodological considerations, from databases to competencies.

Research to help people make informed decisions. Especially interesting was a discussion of the Patient-Centered Outcomes Research Institute (PCORI), the research entity which was mandated by the 2010 Patient Protection and Affordable Care Act. Read the rest of this entry ?

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