Posts Tagged ‘Nursing’


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 ?


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 ?


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 ?


Drive for Show, Putt for Dough: A Cliche With Some Truth for Nursing

March 13, 2015

By Clint Lange, BSN, RN, a MICU nurse at University Hospital, San Antonio, Texas.

Wikimedia Commons

Wikimedia Commons

Before becoming a registered nurse, I was a resident in the wonderful world of professional athletics, where cliches are fed to you almost as much as protein shakes and supplements.

I was a golfer, and golfers are the worst in terms of cliches. I sprained my eyes rolling them so much while listening to desperate golfers try to rationalize their poor performances or give themselves some hope. “I gave it 110%.” Ever take a math class? Because what you are saying isn’t possible. “It ain’t over till it’s over.” After that abysmal last hole, you are, in truth, officially mathematically eliminated from this tournament. For you, it’s over.

I’ll admit it, I’m cynical. I didn’t see the merit in cliches then and to a great extent I still don’t. But I have something else to admit; I’m kind of missing cliches. It seems one can’t quit them cold turkey without having withdrawal.

Or it could simply be that I played in a golf tournament recently for the first time in years, and I couldn’t help thinking about one of golf’s most-used phrases: Drive for show, putt for dough. It simply means that driving the ball is very flashy and fun to watch, but it is generally the guys or gals who are making putts who win the events and the most prize money. In the tournament, I drove it fine but didn’t make enough putts, thus finishing low in the prize money.

What’s alarming to me is that I’m finding it hard not to retrofit the aforementioned cliche into nursing, as I see many similarities. There are aspects of nursing that are flashy and make us seem better than our colleagues, while the other more mundane aspects that are more likely to be overlooked by our peers are really what make us successful and valuable nurses to our facilities—and more importantly, to our patients.

For the nongolfers, further explanation of components of the cliche is warranted. Driving is the first shot one takes on the longer golf holes using what is called a driver. The driver is the club in the golfer’s arsenal that they spent the most money on, produces the longest shot, loudest noise, and the most oohs and aahs from the gallery. There are even long drive contests where musclebound men get all medieval on the ball, to the delight of onlookers for prize money.

These are truly the “protein shake” professional golfers. In comparison, putting is anemic. It is in some cases a tap of the ball to finish out a hole. It doesn’t take much strength to do it, but each putt counts for as many strokes as a ball that was crushed 315 yards with a driver.

What it does take is repetition, discipline, and courage. We’ve all been exposed to “drive for show” nurses. These may be the ones who point out perceived flaws in care during bedside report in order to look good to the patient and family. These are also the ones who make the patient nice and pretty at the end of the shift while practically neglecting the patient for the previous 11 and a half hours. In the same vein, they are the ones who have checked the boxes for all of the duties that were completed on the task list while, in fact, not completing them. Read the rest of this entry ?


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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