Archive for the ‘professional identity’ Category

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On Euphemisms and Learning to Be Present

November 28, 2011

By Alicia Marie Hinton, who is a BSN student at the College of New Rochelle School of Nursing in New Rochelle, NY. This is her first post for this blog.

by grepsy, via flickr

My senior year preceptorship was an assignment on a palliative and acute care unit at a busy medical center. When I received the assignment, I prayed that no patient of mine would die during my time on the unit. Every nursing student is afraid of their first patient death. Simulation and course work prepare students in various ways for this experience, but nothing can really prepare you for the emotions you’ll feel. Some students experience a patient death during an undergraduate nursing program, but for others it may not happen until their first year or two working as an RN. I hoped to never endure it, but knew it was inevitable.

During report, working alongside my preceptor, I listened anxiously to the status of the various patients. Since my first day on the unit, I’d practiced my therapeutic techniques and researched different cultural needs pertaining to the death of a patient. I felt culturally competent and well informed about what a nurse should do when a patient dies, but I couldn’t shake my fear. What would I say to the family? Would they value my presence?

Finally, during morning rounds on my third day on the unit, I was told that a certain Mr. P wasn’t doing too well and might “expire” that day. Our focus would be to provide comfort for him and his family.

How did they know he was to “expire”? Was that the politically correct term for dying? I was familiar with “passed away,” “deceased,” or “gone to a better place.” But the word “expire” didn’t feel right. I’d cared for Mr. P since his admission and interacted daily with his family, and news of his impending death hit me hard, increasing my anxiety about how I’d respond when it happened. While I was anxious about my own feelings about the patient’s death, I was preoccupied with my ability to comfort that family. Read the rest of this entry ?

Posted in nursing students, palliative care, professional identity | Tagged , , , , , | 7 Comments »

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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

Posted in nursing perspective, patient perspective, professional identity | Tagged , , | 2 Comments »

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Physician-centric vs. Patient-centric?

November 16, 2011

By Shawn Kennedy, AJN editor-in-chief

Last week, we posted here a piece by AJN’s clinical managing editor Karen Roush, decrying the use of the term “physician extender.” It reminded me of a recent article from the New York Times on nurses with doctorates, which reported that if some physicians have their way and their legal strategy succeeds, they will be the only group permitted to use the honorific “doctor.”

Degrees vs. licenses. This borders on the ridiculous, as the title is an academic title that signifies achievement in a field of study; it is not a license. Doctoral degrees are awarded in just about every field of study, from astronomy to zoology. Physicians are awarded a doctor of medicine, dentists are awarded a doctor of dental science, and so it goes. In health care, there are dentists, psychologists, social workers, physical therapists, pharmacists, and yes, nurses too, with doctoral degrees. Nurses have been earning PhDs and EdDs (doctorates in education) and the DNSc (doctorate in nursing science) for years, and now there’s a new nursing doctorate degree—a DNP, doctor of nursing practice—that’s specific to nurses in clinical practice. They are still licensed as nurses, as that’s what they are.

This parochial thinking is held by those physicians (not all, but far too many) who still adhere to the traditional view that they, and they alone, know what’s best for patients and for health care; they’re in favor of teamwork, but only as long as the team recognizes that they are the leaders and decision makers.

Both the media and the health care system bear some responsibility for this. The system itself is physician-centric rather than patient-centric—hospital policies, practitioner admitting privileges, purchasing (especially in the OR), and scheduling have often developed around physician preferences; reimbursements almost always must go through physicians, whether or not they’re actually involved in the delivery of care.

Most media portrayals, both fiction and documentary, focus on physicians as the only important providers in health care, relegating other health professionals to low-level supporting roles (or, as Roush noted,“extensions” of physicians). Read the rest of this entry ?

Posted in advocacy/political action, legal issues, media depictions of nursing, nurse practitioners, professional identity, Shawn Kennedy, AJN editor-in-chief | Tagged , , , | 1 Comment »

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Nurse Practitioners Are Not ‘Physician Extenders’

November 11, 2011

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

“Physician extender.” It’s way past time to kill that term.

A study published in the October issue of Surgery found that adding an NP to the surgical team decreased the number of unnecessary ED visits by 50% and increased the use of visiting nurse, physical therapy, and occupational therapy services. A Medscape article (registration required) on the study explained the importance of the findings in this way: “According to the researchers, physician ‘extenders,’ such as NPs, help maintain continuity of care while resident work hours are kept at a maximum of 80 per week. . . .”

Sure enough, the stated purpose of the study was to determine if “integrating this physician extender into the surgery team” would improve outcomes and resource allocation. Ouch.

Experts in our own right. Nurse practitioners are not physician extenders. We are highly skilled and educated nurses who provide evidence-based care grounded in the nursing model. We are not “extensions” of anyone. We are colleagues and collaborators, independent clinicians and experts in our own right. Our purpose is to provide comprehensive care, promote health, educate, and advocate. It is not to relieve interns, supplement physician education, or be the low-cost alternative when physicians have to “do more with less,” as Medscape quoted one of the study authors. Yes, we should be integrated into health care teams, surgical and otherwise—because nurses provide a distinctive aspect of care that research has repeatedly shown to be essential to good patient outcomes. Read the rest of this entry ?

Posted in media depictions of nursing, nursing perspective, nursing research, professional identity | Tagged , , , , | 7 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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Legacy of the Living Legends: Slackers Need Not Apply

October 27, 2011

By Shawn Kennedy, editor-in-chief

Earlier this month, I attended the American Academy of Nursing 38th Annual Meeting and Conference. With e-mails flooding my inbox and a full meeting agenda over the next few days, I was thinking of skipping the 2011 Living Legends event that took place on the first evening. Thankfully, an old friend, nurse historian Sandy Lewinson, talked me into going—it was one of the more memorable nursing events I’ve attended.

The academy honors “Living Legends” in recognition of the multiple contributions these nurses have made to the profession and the impact these contributions have made on health care in the United States and abroad. This year’s honorees are shown in the photo, from left: May L. Wykle, Meridean L. Maas, Ada Sue Hinshaw, Suzanne Lee Feetham, and Patricia E. Benner.

Credited with such achievements as creating a nursing taxonomy on nursing error, building the science of pediatric nursing in the context of the family, conducting ground-breaking nursing research, developing and implementing professional nurse governance in employing organizations, promoting policy change, and addressing the nursing shortage, these nurses join 77 other nursing notables who’ve been so honored since the first class was named in 1994. Read the rest of this entry ?

Posted in nurses, nursing perspective, professional identity, Shawn Kennedy, AJN editor-in-chief | Tagged , , , | 2 Comments »

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CMS Proposing New Hospital Regulations—How Will the Changes Affect Your Delivery of Care?

October 18, 2011

The below information on proposed changes has been shared with AJN by Jeannie Miller, MPH, RN, Deputy Director, Clinical Standards Group, Office of Clinical Standards and Quality (CSG/OCSQ) of the Centers for Medicare and Medicaid Services (CMS).

The Centers for Medicare and Medicaid Services (CMS) has proposed revisions to the hospital Conditions of Participation, the criteria hospitals must meet to be reimbursed for services by Medicare/Medicaid. The changes are needed to remove unnecessary and burdensome regulations that create barriers in care delivery. The changes, if adopted, include:

  • Broadening the concept of “medical staff” to include other practitioners, including APRNs, PAs, and pharmacists, practicing within their scope of practice and in accordance with state law.
  • Changes in nursing care planning to allow for a stand-alone plan or an integrated plan with other disciplines.
  • Allowing medication orders by practitioners other than physicians where the law and hospital policy allows.
  • Allowing a program for patient or “support person” to administer some medications.
  • Calling for standing orders and protocols to be based on nationally recognized and evidence-based guidelines.

There is a 60-day comment period. The CMS would like your comments. The proposed regulation can be found in full via a link on this page near the bottom: http://www.cms.gov/CFCsAndCoPs/06_Hospitals. Or go directly to the PDF here.

To submit a comment, visit www.regulations.gov, enter the ID number CMS-3244-P, and click on “Submit a Comment.” 

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

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When Being Good Means Looking Bad: An Ethical Quandary for Nurses

October 7, 2011

Performance measurement, an increasingly pervasive trend in health care, is credited with significant improvements in the quality of care . . . . Even so, this is little comfort when a nurse faces a situation where an action necessary for meeting a performance measure isn’t what she or he believes is best for a particular patient. For example, falls are often tallied as a performance measure, but frail patients need to be walked; raising the head of the bed to prevent pneumonia is often counted in performance evaluation but may result in less turning of the patient, which may mean more sacral ulcers—which may or may not be tallied as a separate performance measure.

That’s from an article in this month’s AJN by nurse ethicist Doug Olsen. It’s called “When Being Good Means Looking Bad,” and is about potential unintended effects of some well-intentioned performance measures that don’t easily allow for consideration of clinical context. Olsen writes that the nurse may, in certain situations, find herself or himself faced with three highly imperfect options to choose between:

  • Conform care to get the best score on the performance measurement, although that may mean less than the best care for the patient.
  • Use deception, in the form of a work-around or an outright lie, to give the appearance of meeting the measure—while actually doing what one thinks is best. 
  • Give the best care, document accurately—and accept the consequences.

Olsen explains the ethical principles in play, weighs the options, and then offers nurses some succinct advice for finding a way forward. Please have a look and let us know if you’ve ever experienced such a conundrum.—Jacob Molyneux, senior editor

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Posted in ethical issues, nursing perspective, professional identity | Tagged , , , | 5 Comments »

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