Do we need nurses or not?

Thanks to Wellsphere for inviting me to be one of their featured health care bloggers! Check out the link, there's a lot of interesting stuff happening in the blogosphere, and this looks like a great collection of bloggers, from RNs to MDs, DOs, DMDs, DNPs, you name it.

To better "fit in" with the content on wellsphere I'm shifting the focus to more general issues involving the nursing profession and health care in general. I've gotten a lot of great feedback about my writing over the past couple of months, and my usual "slice of life" ramblings are still available on other blogs on an invite-only basis.

I've been getting a lot of emails lately from editors and content producers asking me to share their articles with my readers. Usually this sketches me out a little, sometimes I feel like I'm now a member of a target market that has a lot of attention focused on it. One of these articles, however, really spoke to me, like someone was reading my mind!

Jen Rotman, who says she's an editor of some kind, sent me a link to this article hosted on onlinenursingdegrees.com about recruitment and retention in nursing, the economic downturn, hiring freezes, all that stuff.

Have you had this experience also? As a new grad, I was surprised by how many facilities were in the middle of a "hiring freeze".

From the article:

Fresh and highly localized industry research is providing much more granular data on nursing staffing levels and needs across dimensions as targeted as a city. For example, the preliminary results from a December 2008 research survey in Houston, Texas (2) identified a targeted need for 5700 more nursing staff. Why? The addition of 3000 patient beds, of course, to the city’s healthcare facilities, compounding an already living and breathing nursing shortage. But it’s not as if 5700 nursing jobs are posted in Houston. MedHunters.com posts 97 open RN jobs right now in metro Houston and most of those are for Med/Surg RNs—oh, and candidates must be “able to write and speak effectively in English.”(3) That sinks the notion of plugging in a boatload of fresh Chinese nursing grads.(4)

…If new nursing grads was the real problem in the first place.

Well, I think it's reasonable to expect nurses to be able to speak and write effectively in english. The class I graduated with had two Chinese women in it. They had been speaking english for different amounts of times, but despite the fact that they said it was a struggle sometimes, they were both extremely articulate and didn't have any trouble communicating with -me-, at least.

In nursing forums across the web more than a few new nursing school grads have been expressing frustration since early Fall at what would seem to be a hiring shut-out. (5) Fewer hospitals, it would seem, are opening their units to inexperienced new RN graduates. These next-gen RNs are perplexed about the alleged nursing shortage, as well, particularly in an industry that drew them into schools with open and exuberant arms in the first place, an industry that claims it can’t get enough of new nursing grads. To quote one of these bamboozled grads, “What gives?”

Here’s one version of an answer: Apparently some hospitals and healthcare facilities have, instead of hiring new nursing grads, managed to inspire experienced nurses to stay on staff, work overtime, or they have otherwise leveraged/manipulated their human resources.(6)

That’s a lot of overtime. What about quality of care? What about the cost of paying experienced nurses for overtime? Let’s see, those 5700 needed RN jobs in Houston – subtract the 97 actually posted – let’s just say 5600 jobs, equals roughly 201,600 overtime hours per week (5600 nurses x 36 hours). Really, are experienced RNs working those apparently needed hours in patient care? Have you heard this excuse, too: would rather hire experienced nurses or retain staff versus spending the money to orient and train new grads. But don’t new grads also come with some much-needed high-tech savvy in a career circle heavy with older nurses with little tech know-how? And time spent orienting is an up-front investment. Can you say, “Mixed messages”?

In some circles, the word in healthcare is “hiring freeze.”

Quietly and without much ado more than a handful of hospitals and healthcare facilities across the country have gone on hiring freezes. The term “hiring freeze” is characteristic of economic direness. It says, “We are not as solvent as you think. We need to shut the gates here and now.” Even one of the most “recession-proof” nursing niches, travel nursing, has been recently affected. In mid-summer 2008 a few news headlines reported that travel nursing jobs were unaffected by the stock market storm. Now it’s clear that the number of jobs open to travelers has also dropped.

To be fair, the only facility that actually told me they were in a "hiring freeze" when I was searching for my first job was a state mental hospital. The community hospitals, however, were all extremely competitive, maybe because that's the environment where new grads can get the most intensive clinical training after graduation. Even without a hiring freeze, being told that there were 15 openings for new grads in one facility and over 150 people applying has to make you scratch your head sometimes.

More on travelers:

Right now 23 states belong to the Nurse Licensure Compact (NLC) program – if you hold a license in one then you are as good as licensed in all of them. It’s a sensible situation and allows travelers to have great mobility among the 23. But if you’re a nurse and eager to take a travel assignment in a state outside the NLC—for example, California, Florida, or New York (ironically, the bi-coastal states with the most travel needs)—then you need to apply directly to that particular state’s board of nursing for licensure. Each state’s licensure costs anywhere between $90 and $250 depending and takes at a bare minimum 2 weeks to secure. Forget about online applications or expedited anything—here is the real nitty-gritty of bureaucratic red-tape; “think” DMV. If there’s a paperwork snafu with a new license expect the delays involved in the back-and-forth of snail-mail to gum up the process, as well. In fact, you’d never know there was any urgency whatsoever to get qualified nurses on the job based on the machinations of the state nursing boards.

I got introduced to the issues surrounding the license compact while I was in school, and it sounds like a complex issue! One of the problems someone mentioned to me was that the AMA is waiting for state boards of nursing to re-open their practice acts so they can swoop in and lobby for reductions in the scope of NP's practice. The compact seems like a good idea to me, though. At the last NSNA convention one of the speakers was talking about how the license compact allows inter-state transmission of disciplinary records regarding individual licenses, and backed up the story with some compelling case studies that indicated that this is a good thing.

Personally, I don't reside in a compact state, but our state -did- recently re-open our practice act to define the role of clinical preceptorship in RN programs, and NPs still practice happily here, so maybe there's some wiggle room. I'm looking forward to getting involved in our state's chapter of the ANA, I did some ad hoc tasks for them back when I was a student. Maybe their conventions aren't as fun as the NSNA conventions (so I've been told), but that sort of thing's always appealed to me anyway.

Anyway, the article ends with a salient question. "Have we bailed out the wrong industry?". I'm no economist, but it does seems as though the priorities are skewed.

I used to think that the main reason there was a nursing shortage was the shortage of nursing faculty (nursingphd.org) in schools. This made sense while I was a student, because I noticed there were hundreds of qualified students competing for less than a hundred slots.

Now, I'm not so sure. Isn't the problem actually that the businesses that employ nurses tend to stretch their labor as thinly as they can get away with? I hypothesized a couple of weeks ago that if the number of nurses available to work suddenly doubled, patient ratios wouldn't improve at all, more facilities would be opened instead.

Tell me what you think.


The epigenetics of the sugar high

There's been a lot of talk in the journals lately about epigenetics, now there's an interesting article in the Journal of Experimental Medicine about how bad habits regarding sugar consumption can actually create genetic changes that can be passed on to offspring.

Couriermail has a breakdown for those of you not inclined to read scholarly articles:

"It is this idea that you are what you eat. Perhaps it's a reflection of what your parents ate, and perhaps what your grandparents ate," he said.

The scientists proved that a single sugar hit, such as eating a chocolate bar, damaged the controls regulating the body's genes for two weeks.

But Professor El-Osta warned that regular poor eating meant the damage would last for months or years, and the real problems caused by an unhealthy diet were deferred until later life.

After having proved the impact of high-sugar foods, the Baker IDI team is now focusing efforts to determine if high fat foods, smoking and other lifestyle-related factors also cause long-term damage to genetic controls, which could then be passed along family bloodlines.


Feedback: the blogging adventure

As I could have expected, when I do finally get some kind of critical feedback on my blog, it comes filtered through a couple of people first and takes on a highly confrontational tone. Ah, the joys of being male and a gender minority. Just like work, you see. Don't bring it up directly, make sure you talk some shit first and build up a good sense of righteous indignation!

Anyway, since this person lives near me, has been to my facility, and most likely knows someone who works there, I've made my most identifiable mirror of this blog (my myspace) private again. I'm loathe to do this, since the myspace mirror gets a couple hundred hits a week and this blog only gets 30 or so, but in light of what some of the gripes were, I figured it would be a good idea temporarily.

Something I hadn't really considered before is that, due to the volume of writing, someone reading only one or two entries might get an extremely polarized opinion that would have been balanced out 2000-3000 words ago or so. I've been accused of being arrogant and looking down on the aides, even though I've written that I get a lot of support from them and give a lot of support back. I vent once in a while when things go sour, but a lot of people use their blogs to vent, and many people do it much more frequently than I do. Is there a perceptible bias here towards venting about things that go wrong as opposed to writing about what's going right? What I might need to consider is that people are only going to read a post or two instead of the last couple of months worth of posts, so perhaps I should make each post itself more balanced.

If I wrote a month ago about how much I'm learning from one of the CNAs and how humbling it was to see her care for a dying patient, and then a month later write about how I think one of the bad-apples is displaying a lot of mal-adaptive behavior, someone can easily get the wrong impression if they only have the time or patience to read one or two posts.

Making each post balanced in this way, though, would get repetitive and time consuming. Ideally people would get more information before making judgments, but I suppose this is not always the case.

It's obvious when someone is complaining about something because they're already defensive or insecure about something, but the other part that I thought would benefit from some open discussion is the whole privacy thing.

I've read the full text of "the act" several times, including a handy list of what is considered "private" information. People I've asked to double-check have indicated that none of that private information is posted here. Ages over 90, specific dates of events, geographic subdivisions smaller than a state, all that stuff. I'm careful, but there's always the possibility I've made a mistake. The complainer, of course, hasn't yet supplied information as to exactly how I've violated the Act.

This person believes that because she has been in my facility and was able to piece together the information, that somehow constitutes a violation. Violations are clearly defined in the act:

`SEC. 1177. (a) OFFENSE- A person who knowingly and in violation of this part--

`(1) uses or causes to be used a unique health identifier;

`(2) obtains individually identifiable health information relating to an individual; or

`(3) discloses individually identifiable health information to another person

Have I done this somewhere? Does the fact that someone else already -knows- the private information magically make something infringe that otherwise wouldn't? A couple of lawyers have told me "no", but it would be interesting to get input from the blogosphere. I've read plenty of blogs of nurses, paramedics and MDs, and if I worked in their facility I would know who they were talking about, but that doesn't make their postings an infringement.

The main reason for keeping my identity obfuscated, besides privacy concerns, is that it would be more difficult to write about work if people FROM work were reading it. If these people are my friends already, and they find it through google or something, that's fine, but there's always the possibility that it could be used against me somehow.

So why continue?

Well, I still think this is important. I'm inspired by the other health care bloggers and want to try to follow their example, whether I agree with what they have to say or not. I'm confident that my blogs comply with the law (feel free to contradict me here, please cite references), however I'm -not- confident that my superiors would be a big fan. It's a tight rope, razor-thin. Thanks for reading so far.

To Review

I'm in the midst of a four-day weekend, a nice break from working five days a week!

When I get back, I have to come in early for a meeting with our director of nursing services. I was wondering aloud what she wanted to meet with me about, when our RN+Reiki master told me that it was about time for my first quarterly review. She told me to expect to get feedback on what I'm doing well and what I need more help with, and then have an opportunity to tell her what I feel is going well and what I think I need more help with. Probably not in that order.

When I was interviewed for this job, the DNS did 90% of the talking. I took this as a bad sign initially, but I've noticed the interview isn't weighted very heavily into hiring decisions. This meeting may have a different tone to it, we'll see.

I feel compelled to over-prepare for this meeting, just like I did for my interview. I've been keeping an ear to the ground, keeping track of what other people have been saying about me via one or two of the other RNs that I feel like I can trust. The main thing, as I've indicated in a previous post, is everyone's hilarious overreaction to the two aides I've written up three times (for a total of three comm. sheets). One of them isn't working there anymore, much to the relief of everyone from the aides to the director of nursing services.

I think the problem here is that the communication sheets are private, where they should be obfuscated and shared with everyone. Doesn't that make sense? That way we can all learn from them.

I remember at the last national student nurse's association convention I had a nice chat with a woman from the national council of state boards of nursing education. She was giving a lecture about disciplinary cases from different states and what we can learn about them. I approached her afterwards and asked her if she had ever considered making a public "lesson's learned" database with the HIPAA details removed. This is something I saw the department of energy do back when I worked for a defense contractor. She thought it was a good idea. I still do.

Another big part of the problem is how those communication sheets are received by the people who get written up. I was actually "written up" by the RN+Reiki Master, and it was a very productive experience. We brainstormed other methods to prevent similar mistakes from happening in the future and decided on the best one to implement.

If I'm going to model the correct way to "take" one of these communication sheets, maybe the best thing to do is invite the aides to write ME up when they see me doing something wrong. I am new, after all! Maybe after they've had the chance to do that, they'll be able to see the correct way to respond to that situation. The way I show them.


On a lighter note, I'm going to the NSNA convention in Nashville TN! It's in the middle of April, and this will be the first year I fly solo as a sustaining member instead of as the president of a school SNA chapter.

Now that I'll be free of my parliamentary and organizational duties, I should have more time to soak up the focus groups and presentations. There were lots of good ones I missed the past three times around, so I'm looking forward to perusing the line up for this year.

The convention is at a Gaylord resort again (the Gaylord Opryland), and after the experience of hanging out at the Gaylord Texan last year, I'm definately excited!

I'll make sure to take lots of pictures. Maybe I'll see some of you there!



This post has been moved to "SNiF-Confidential", an invitation-only blog. Now accepting regular or guest contributors!


'Till death

I'm all through covering the first shift supervisor shifts for now, and I'm on my way back for some 3-9 shifts for the rest of the week.

I really enjoyed first shift. It was nice to work with the "A" team, and having the therapy director and social worker around was a great experience. When I come up with questions I can just ask! We got a lot of things done, they asked a lot of me and I asked them for a lot in return. Very productive.

Another fun thing about supervising on the day shift is that when I need to get orders from our house MD, he's actually in his office at his family practice. No more asking to see who's on call for him, no pensively waiting for a page to be returned. There he is!

It's a busy shift and there's a lot to be done. I found myself helping the CNAs with toileting and hygene just as often as I was being pulled in a dozen different directions by therapists and aides to perform RN assessments for changes in condition and new findings.

The wandering engineer failed his voiding trial. I was told not to hold out too much hope that it would succeed, since when his condition was initially discovered he had 3000 cubic centimeters of urine in his bladder. I tried every trick in the book. Crede's maneuver, peppermint spirits, the works. His bladder seemed distended with only half a liter of urine in it, so I had hoped his bladder regained some of the tone it had lost. Next time I'm in I guess I'll just see what the urologist wants us to do next.

While spending a lot of time with him encouraging him to void, I spent a lot of time talking to his wife. Some people at our facility have labeled her "histrionic", but she's dealing with an extremely difficult situation, and I took plenty of time to council her about how to prompt him and how to deal with him without getting frustrated. They're such a sweet couple, and when things are difficult for her I encourage her to give her husband a hug and come back to visit again later. I've overheard some of the nurses saying that she wish she wouldn't come to visit him because it gets him "riled up", a point of view that nauseates me when I hear it expressed. Maybe they won't live together again in an independent living situation, but at least they're close by.

When he married her, I imagine, he was betting that she was the one that gave him the best hope of being loved and cared for throughout his lifespan. 'Till death separates them. Now, his needs are too complex for one person to handle themselves. This is where we come in. We're an extension of her love for him, not a replacement for it. Death will separate us eventually, but until then, there's work to do. The work of living, loving, laughing, and taking the good days with the bad. It comes to us all, and if I can help her with this maybe someday someone will help me.


so tired...

It's not the first time it's occurred to me...but now that you're all gone, this place has turned into exactly the kind of thing you would have enjoyed. The coffee shop is streaming all the music we used to listen to together over the internet. The recording studio I just came back from was decorated in a fashion I think you would have particularly liked. The bands playing at the bar are ones you would have wanted to see.

The band I just recorded with is called "Gone for Good", and the significance isn't lost on me. I'll post a track later, if I can get away with it.

The people here now are people you would have liked, people you would have had a lot to talk about with, people who remind me of you more often than I would like.

I suppose I'm usually only this maudlin when I haven't slept. Then again, when I'm deprived of sleep is when I'm usually the most creative. Of course, when I haven't slept I can't help but think of you.

So it is with the movies, books and music that the people around here enthusiastically try to share with me. They elicit only cold stares and hurried changes of subject. Without you to share them with each one is a pointed insult, unintentional though it might be.

Of course, this is the part where I start talking about what a great Nurse I'm becoming, so you can point at that and say "see, this had to happen so you could get where you are now". That's crap, of course. A cop-out. I was on my way here with or without you. Getting my license, an extremely well-paying job and the respect of my peers, superiors and subordinates (well, most of them anyway) was inevitable. I never doubted it for a moment, not since the first time I set foot on a med/surg unit. I guess we just weren't prepared for the changes that would set in motion.

Like so many other people who do this job well, I'll work, and work, and work, until I expire. Maybe in lieu of a family I'll have a class of nursing students someday, something to leave behind.

Of course, I still think there's a better than 50% chance advances in technology will extend our lifespans indefinitely. Wouldn't that be something.


The Hot Seat

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The continuing education of one RN supervisor

I spent a lot of time on the phone with MDs on my last overnight shift. Our usual house doctor wasn't on call, one of his associates was. The other nurses seemed surprised that he called me back so many times. The trick, they told me in school, was to be concise and have all of the relevant information at hand. I also keep the portable in my pocket if I'm away from the desk so I can pick up every time they call.

It was very educational for me, I'm lucky enough to work somewhere where I can preemptively write telephone orders for labs and treatments, and I'm starting to get the hang of which lab results the MD wants to see before he/she'll give orders for different situations. A lot of it's common sense, but getting to know the on-call MDs through routine interactions has been instructive. If one of my residents is passing blood in her stool, I can get that lab draw for a CBC and Pro Time -before- I call for orders. I actually write the telephone order for the labs first, then when they get faxed over I page the MD for orders so I only have to bug them once instead of twice.

I'm starting to see what a complex issue infection control is. We always have a few people on antibiotics, mostly vancomycin, keflex or flagyl (or some combination of those). When we detect a new infection, we send out a sample if we can, but in many cases there's no drainage to send out for a culture-and-sensitivity, and antibiotics are ordered empirically. Let's see what this one does! I find that concerning but it seems like standard fare. What if the organism is resistant? When we DO get a C&S back, what I usually see nurses doing is tell the MD that it is susceptible to a particular antibiotic we have in stock, even if it's not the therapeutic agent that the bacteria is MOST susceptible to, information that no one seems interested in.

Something new to me in this job that I never saw in the hospital was the use of probiotic supplement pills alongside antibiotic therapy. This makes sense to me, since lost of intestinal flora can be a big problem for elders taking antibiotics. Is this a new thing? How come I hadn't heard of this until I started working in a SNF? Culturelle or VST#3 are the probiotics I see most frequently. I haven't looked at any of the research regarding outcomes with their use with antibiotic therapy, that might be a fun weekend research project for me to undertake sometime.

I find myself laughing at work a lot. I like working with the younger LPNs (well, I say younger but they're older than I am). One of them was surprised when I told them that I love my job. They're the closest things I have to preceptors in this job, I should make sure they know how much I appreciate them.



Sometimes I think the only way to tell there's a holiday at my facility is to see what the aides are wearing. Long red caps with white puffballs on the end? Must be christmas. Plastic top-hats that say "happy new year"? Must be new year's.

Another hint that there's a holiday going on is the massive amount of LOAs (leaves of absence). I thought this would make the day go easier, but in reality it takes away some of my options for meds and treatments, and I find myself stretching some of the "rules" that got beaten into me in nursing school. Specifically I'm talking about pre-pouring medications.

My medication cart has five drawers, a locked narcotics box, and all of the medications for about 17 people; some of whom take 20-30 medications daily. House stock medications (colace, aspirin, miralax, vitamins, etc), lidoderm patches, glucometer equipment, pretty much everything I need. The only thing I have to walk to our medication room (which is about 100 feet away from the farthest point on my side) is refrigerated medications (liquid vancomycin, for example).

During holidays, many of the residents go out with family. Some go to restaurants, some go to the home of a family member, some visit their spouses or friends on the independent living side of our facility. More than once I've found myself standing in front of a room with no one in it, holding a soufflé cup full of pills (and maybe a filled syringe or two) for an absent resident. Rather than waste the expensive and possibly controlled medications, I'd lock them up, soufflé cup and all, maybe with initials etched into the side with a pen.

Now, if I were orienting or training junior faculty, I would discourage this practice, just as I was discouraged from doing it back in school (it -is- slightly different having an automated medication dispenser around, however). Too many things could go wrong. Were there 9 pills in that cup or 11? There's a pill that looks like it fell outside the cup. Is it zolpidem or metoprolol? Or maybe just an aspirin? Better make sure to lock that cart up every time you step away!

Despite the fact that I think it's a bad idea and I've been trained to think it's a bad idea, I still do it occasionally. Always within reason. Never more than one or two cups, separated in different drawers, with initials written on them. Any cups containing narcs go in the narc box, tucked in the back, locked under a separate key. It's a sad fact of our situation, perhaps, that rules have to be bent once in a while in order to get everything done and still leave 30 minutes late instead of 75.

Some of the more experienced nurses do this also, and they all sing the same chorus when asked. "Do what you're comfortable with". Take risks if you must, but be prepared for the consequences. One particularly competent nurse pre-pours only the house-stock medications like stool softeners and vitamins, so she doesn't have to keep reaching for the large bottles every time. Makes sense I suppose.


The rest of this post has been moved to "SNiF-Confidential", an invitation-only blog. Now accepting regular or guest contributors!