That was worth reading.
Yet another valuable Atul-Gawande-penned _New Yorker_ article contributing to the body of knowledge on healthcare dollars & how and where they're spent:
http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande
Thoughts on obstacles to evidence-based practice in medicine:
http://bengoldacre.posterous.com/why-is-medicine-often-not-evidence-based
And I finally read Abraham Verghese's _Cutting for Stone_. Lovely, mostly believable paean to medicine and surgery despite a maddeningly 2-dimensional female foil whose only existence is to let the protagonist's destiny unfold as needed in the book.
Saturday, February 12, 2011
Thursday, January 27, 2011
Soapbox: Permanent Novice
In my psysch nursing class the other day, our instructor got on her soapbox for a moment about nursing. She said nurses are in the privileged position of always being a novice, for each patient, every time. Patients know if you are pretending to listen to them, so we have to learn how to really listen, so that we can learn from the patient. The patient is the expert on herself, and the nurse is there to listen and learn. I like this.
Thursday, January 20, 2011
Nursing Defined (self-plagiarism)
About a week ago, I sat down & whipped out a short essay for a 1-credit class, in response to two articles we had to read regarding nursing. I didn't do a fabulous job, but because of the self-referential nature of the assignment, it seems worth re-posting here.
****
Nursing Defined
Defining is a process that involves deciding upon criteria for inclusion and exclusion. Providing a definition of nursing, or listing the criteria that one must meet to be called a nurse, reminds me somewhat of the activity of declaring who is a Christian. Any licensed practical nurse (LPN) or non-bachelor-prepared registered nurse (RN) would be insulted—and rightly so—were I to tell them that Luther Christman (1998) thinks that what they spend their time doing cannot, or should not, properly be called nursing, since they were not prepared by a four-year university education. While most of the Southern Baptists in the Alabama town where I was raised would swear up and down that Mormons are not Christians, Mormons I know say that they are. The members of a group make up the group’s inclusion and exclusion criteria, and outsiders, those who do not think of themselves as belonging, usually could not care less about such internecine controversy.
I agree with Christman that nurses’ image in the public eye could be better (1998), and a combination of the public’s experience with point-of-care delivery and what they see on television is likely the source of this image. Nonetheless, the “solution” he offers to this problem is impractical and naïve, not merely because there are so many entrenched interests opposed to it. Demanding that all nurses spend even more time and money on their educations will simply mean that Christman’s “real nurses” will be more expensive to hire, so current trends will continue: Certified Nursing Assistants and LPNs will be trained to stretch the bounds of their scope of practice in ever-more creative ways so that they can take over most of the tasks that RNs do, and healthcare facilities won’t have to budget so much for personnel [1]. And their patients still won’t keep straight who can properly be called a nurse, because they won’t care. Patients will only know or notice who is caring for them at bedside, and whether this person does so in a way that makes them happy. As for Christman’s complaint that more educated nurses eventually move out of the realm of patient care (1998), this could be solved in a number of ways that do not involve his never-to-be-realized pipe dream of a 100% BSN-prepared nursing staff, including “lateral” promotion whereby someone gets meaningful salary increases without being asked to leave bedside nursing. Likewise, his important critique of nursing instructors often being many years out of practice of bedside nursing could be accomplished by having educating institutions require that faculty spend a minimum number of hours per month working in bedside nursing, which presumably many of them require already.
Rozella Schlodtfeldt’s (1986) description of nursing seems nearly orthogonal to Christman’s. She barely touches upon nurses’ education or preparation. Rather, she addresses nursing practice and scholarly inquiry. She fears that the American Nursing Association’s definition of nursing in its 1985 Social Policy Statement, and nursing diagnoses themselves, will induce nurses to focus on human sickness and abnormality, rather than human health and health-seeking behaviors. This seems unreasonable to me, given that the _Nursing Diagnosis Handbook_ contains plenty of diagnoses that relate to wellness and health-seeking behaviors, and “deficient knowledge” diagnoses that require assessing what the client already knows and treating them as a health-seeking agent. Her definition of nursing as “the appraisal and the enhancement of the health status, health assets, and health potentials of human beings” (Schlodtfeldt, 1987, p. 67) certainly approaches sickness and health from the direction of health, but I do not think it would cause a change in the diagnoses present in the Handbook, unless someone took the time to tortuously reword them to provide for this slight change in emphasis at the cost of clarity.
When I studied comparative religion, I approached religion from an anthropological perspective. I was much less interested in what a particular religion’s canon declared that the religious practitioner was, or should be or do, or could not be or do. Rather, I was interested in the actions of those who called themselves believers and practitioners. Likewise, while I find studies of what practices and medications prove effective in healthcare settings interesting, I am far more interested in when, how, and why these evidence-based procedures are and are not implemented. I think the entire field of healthcare would benefit from relatively more research on factors that affect the (non)implementation of interventions proven to be effective, rather than looking for new interventions.
A nurse, to me, is someone who has undergone a specific amount of training to become a nurse, and who calls herself a nurse, as do her coworkers and clients. She engages in tasks that touch upon human dignity and are often quite high stakes, require an enormous amount of organizational ability, can employ analysis but don’t necessarily, and likely has to work hard. This is different from an ideal nurse. An ideal nurse is an effortless multi-tasker and communicator, endlessly compassionate, intellectually curious, intolerant of inefficiency in the healthcare system while tolerant of the humans who create the inefficiencies, prompt to adopt evidence-based changes in practice, a tireless worker, and kind and sociable without imposing her own emotions on any situation. Much like Jesus, the ideal nurse is a model we can carry in our heads and hearts as we carry out the tasks we have to do, and to which we can compare ourselves, hopefully with compassion, as we fail to do exactly what the Ideal Nurse would have done in the same situation. Certainly I hope that a drive for self-improvement, and for improving the system in which humans experience sickness and health, is a part of every nurse, but even this cannot be declared the sine qua non that makes a nurse a nurse.
[1]
As a teaching “assistant” at University XXX, I taught 300-level Spanish courses on my own. I was far cheaper to UX than faculty or even assistant professors would have been. I was a competent and well-prepared instructor, but I could not have been, and UX still would have been saving money. As a further example of outsiders’ indifference to rank and role inside groups they don’t belong to, students often called me professor and were confused when I corrected them.
References
Ackley, B., & Ladwig, C. (2011). Nursing diagnosis handbook: A guide to planning care ( 9th ed.). St. Louis: Mosby.
Christman, L. (1998). Who is a nurse? Image: Journal of Nursing Scholarship, 30 (3), 211-14.
Schlotfeldt, R. (1987). Defining nursing: A historic controversy. Nursing Research, 36(1), 64-
67.
****
Nursing Defined
Defining is a process that involves deciding upon criteria for inclusion and exclusion. Providing a definition of nursing, or listing the criteria that one must meet to be called a nurse, reminds me somewhat of the activity of declaring who is a Christian. Any licensed practical nurse (LPN) or non-bachelor-prepared registered nurse (RN) would be insulted—and rightly so—were I to tell them that Luther Christman (1998) thinks that what they spend their time doing cannot, or should not, properly be called nursing, since they were not prepared by a four-year university education. While most of the Southern Baptists in the Alabama town where I was raised would swear up and down that Mormons are not Christians, Mormons I know say that they are. The members of a group make up the group’s inclusion and exclusion criteria, and outsiders, those who do not think of themselves as belonging, usually could not care less about such internecine controversy.
I agree with Christman that nurses’ image in the public eye could be better (1998), and a combination of the public’s experience with point-of-care delivery and what they see on television is likely the source of this image. Nonetheless, the “solution” he offers to this problem is impractical and naïve, not merely because there are so many entrenched interests opposed to it. Demanding that all nurses spend even more time and money on their educations will simply mean that Christman’s “real nurses” will be more expensive to hire, so current trends will continue: Certified Nursing Assistants and LPNs will be trained to stretch the bounds of their scope of practice in ever-more creative ways so that they can take over most of the tasks that RNs do, and healthcare facilities won’t have to budget so much for personnel [1]. And their patients still won’t keep straight who can properly be called a nurse, because they won’t care. Patients will only know or notice who is caring for them at bedside, and whether this person does so in a way that makes them happy. As for Christman’s complaint that more educated nurses eventually move out of the realm of patient care (1998), this could be solved in a number of ways that do not involve his never-to-be-realized pipe dream of a 100% BSN-prepared nursing staff, including “lateral” promotion whereby someone gets meaningful salary increases without being asked to leave bedside nursing. Likewise, his important critique of nursing instructors often being many years out of practice of bedside nursing could be accomplished by having educating institutions require that faculty spend a minimum number of hours per month working in bedside nursing, which presumably many of them require already.
Rozella Schlodtfeldt’s (1986) description of nursing seems nearly orthogonal to Christman’s. She barely touches upon nurses’ education or preparation. Rather, she addresses nursing practice and scholarly inquiry. She fears that the American Nursing Association’s definition of nursing in its 1985 Social Policy Statement, and nursing diagnoses themselves, will induce nurses to focus on human sickness and abnormality, rather than human health and health-seeking behaviors. This seems unreasonable to me, given that the _Nursing Diagnosis Handbook_ contains plenty of diagnoses that relate to wellness and health-seeking behaviors, and “deficient knowledge” diagnoses that require assessing what the client already knows and treating them as a health-seeking agent. Her definition of nursing as “the appraisal and the enhancement of the health status, health assets, and health potentials of human beings” (Schlodtfeldt, 1987, p. 67) certainly approaches sickness and health from the direction of health, but I do not think it would cause a change in the diagnoses present in the Handbook, unless someone took the time to tortuously reword them to provide for this slight change in emphasis at the cost of clarity.
When I studied comparative religion, I approached religion from an anthropological perspective. I was much less interested in what a particular religion’s canon declared that the religious practitioner was, or should be or do, or could not be or do. Rather, I was interested in the actions of those who called themselves believers and practitioners. Likewise, while I find studies of what practices and medications prove effective in healthcare settings interesting, I am far more interested in when, how, and why these evidence-based procedures are and are not implemented. I think the entire field of healthcare would benefit from relatively more research on factors that affect the (non)implementation of interventions proven to be effective, rather than looking for new interventions.
A nurse, to me, is someone who has undergone a specific amount of training to become a nurse, and who calls herself a nurse, as do her coworkers and clients. She engages in tasks that touch upon human dignity and are often quite high stakes, require an enormous amount of organizational ability, can employ analysis but don’t necessarily, and likely has to work hard. This is different from an ideal nurse. An ideal nurse is an effortless multi-tasker and communicator, endlessly compassionate, intellectually curious, intolerant of inefficiency in the healthcare system while tolerant of the humans who create the inefficiencies, prompt to adopt evidence-based changes in practice, a tireless worker, and kind and sociable without imposing her own emotions on any situation. Much like Jesus, the ideal nurse is a model we can carry in our heads and hearts as we carry out the tasks we have to do, and to which we can compare ourselves, hopefully with compassion, as we fail to do exactly what the Ideal Nurse would have done in the same situation. Certainly I hope that a drive for self-improvement, and for improving the system in which humans experience sickness and health, is a part of every nurse, but even this cannot be declared the sine qua non that makes a nurse a nurse.
[1]
As a teaching “assistant” at University XXX, I taught 300-level Spanish courses on my own. I was far cheaper to UX than faculty or even assistant professors would have been. I was a competent and well-prepared instructor, but I could not have been, and UX still would have been saving money. As a further example of outsiders’ indifference to rank and role inside groups they don’t belong to, students often called me professor and were confused when I corrected them.
References
Ackley, B., & Ladwig, C. (2011). Nursing diagnosis handbook: A guide to planning care ( 9th ed.). St. Louis: Mosby.
Christman, L. (1998). Who is a nurse? Image: Journal of Nursing Scholarship, 30 (3), 211-14.
Schlotfeldt, R. (1987). Defining nursing: A historic controversy. Nursing Research, 36(1), 64-
67.
3rd quarter and all is well
My program has some bizarre & distressing organizational issues, but I'm still inspired by all my various clinical instructors/preceptors and my class instructors, by how they practice, teach, and manage and think about their own lives. I'd say 90% of the (very large amounts of) time I spend doing school-related clinic, work, class/clinic preparation, follow-up, writing, reading, etc. is enjoyable and thought-provoking in the best ways.
Nursing school has been good at really teaching me to prioritize, by example and by necessity. Necessity: I just have less time, so I'm making sure I spend not-school-related time doing exactly what I want or need to be doing, which turns out to mostly be hanging with my family. Example: nursing is all about teaching patients/clients in various compromised states of health to prioritize so they can "conserve energy" and use their time in the ways most important to them. As a classmate of mine said to me the other day, someone with COPD (chronic obstructive pulmonary disorder) has to choose between having sex with their spouse and going to the grocery store that day, and needs help adjusting to the idea of planning accordingly. And that's ok. One cannot do it all, one shouldn't try to do it all, and it's a waste of precious energy to even spend time worrying about the "all" one isn't doing. I also find that I'm enjoying the time I spend with my daughter more and more--in part, this is because she is 3, and everyone says 3 is "such a great age, watch out for later." But it's also because of how precious this time with her feels to me.
All the things I'm learning, and strategically "thinking like a nurse" in terms of assessment, prioritization of my time and client'/patients', and provision of care, have been the final nail in the coffin, for me, of the Cartesian mind/body distinction. The distinction had started to erode years ago through a combination of lots of yoga and being humbled by how birth control hormones affected what I thought of as my stable self and personality. But pharmacology, therapeutic-nursey thinking, my own experiences with therapy and couples workshops, and some profound meditative experiences in yoga, have finally taught me it's a useless distinction to make.
One other cool revelation I've had recently: in the midst of all our class, lab practicums, and clinic work, we have 3 seminars this quarter for which we don't have to do any prep work. We just get to go, listen, think, absorb, and ask questions. Our first one was a 2.5 hour presentation on pain and pain management. Fascinating stuff. And a big part of it is realizing where our own biases as healthcare providers are, and being suspicious of them, because someone's 10/10 pain might be provoked because of having a sheet dragged over their toes because they have a nerve problem, and it is NOT my job to think or act as if they aren't experiencing that much pain, or they're a wimp, or that "can't happen," etc. One person's 10/10 pain might look and sound, in terms of their expression of it, like another person's 4/10 pain. Some cultures disapprove of outward acknowledgment of pain.
Pain is now widely being called & considered the 5th vital sign (temperature, blood pressure, pulse/heart rate, and respiration rate are the main 4), and it's not a sign, because I cannot objectively assess it. It is the patient's subjective experience, but HCPs need to pay as much attention to it as a sign, because of all the ways it affects the patient and their future healing/functioning/mental and emotional health, etc. Anyway, it wasn't much of a stretch for me to say to myself, "yes, someone's pain is their own, and I CANNOT tell them they don't actually feel that bad, or shouldn't, because it's not my body and it's not what I'm feeling." This is a full admission on my part of others' right to their subjective experience. So the neat part is that I finally have the analog I needed to think about other people's subjective experiences of the world in general, and their emotional reactions to it. It doesn't even make sense for me to think, or tell someone, that they should or shouldn't be angry, sad, happy, resentful, etc. I don't know what it feels like to be them, and cannot. Neat! I have applied logic to my own attempts to apply logic where it doesn't belong.
Nursing school has been good at really teaching me to prioritize, by example and by necessity. Necessity: I just have less time, so I'm making sure I spend not-school-related time doing exactly what I want or need to be doing, which turns out to mostly be hanging with my family. Example: nursing is all about teaching patients/clients in various compromised states of health to prioritize so they can "conserve energy" and use their time in the ways most important to them. As a classmate of mine said to me the other day, someone with COPD (chronic obstructive pulmonary disorder) has to choose between having sex with their spouse and going to the grocery store that day, and needs help adjusting to the idea of planning accordingly. And that's ok. One cannot do it all, one shouldn't try to do it all, and it's a waste of precious energy to even spend time worrying about the "all" one isn't doing. I also find that I'm enjoying the time I spend with my daughter more and more--in part, this is because she is 3, and everyone says 3 is "such a great age, watch out for later." But it's also because of how precious this time with her feels to me.
All the things I'm learning, and strategically "thinking like a nurse" in terms of assessment, prioritization of my time and client'/patients', and provision of care, have been the final nail in the coffin, for me, of the Cartesian mind/body distinction. The distinction had started to erode years ago through a combination of lots of yoga and being humbled by how birth control hormones affected what I thought of as my stable self and personality. But pharmacology, therapeutic-nursey thinking, my own experiences with therapy and couples workshops, and some profound meditative experiences in yoga, have finally taught me it's a useless distinction to make.
One other cool revelation I've had recently: in the midst of all our class, lab practicums, and clinic work, we have 3 seminars this quarter for which we don't have to do any prep work. We just get to go, listen, think, absorb, and ask questions. Our first one was a 2.5 hour presentation on pain and pain management. Fascinating stuff. And a big part of it is realizing where our own biases as healthcare providers are, and being suspicious of them, because someone's 10/10 pain might be provoked because of having a sheet dragged over their toes because they have a nerve problem, and it is NOT my job to think or act as if they aren't experiencing that much pain, or they're a wimp, or that "can't happen," etc. One person's 10/10 pain might look and sound, in terms of their expression of it, like another person's 4/10 pain. Some cultures disapprove of outward acknowledgment of pain.
Pain is now widely being called & considered the 5th vital sign (temperature, blood pressure, pulse/heart rate, and respiration rate are the main 4), and it's not a sign, because I cannot objectively assess it. It is the patient's subjective experience, but HCPs need to pay as much attention to it as a sign, because of all the ways it affects the patient and their future healing/functioning/mental and emotional health, etc. Anyway, it wasn't much of a stretch for me to say to myself, "yes, someone's pain is their own, and I CANNOT tell them they don't actually feel that bad, or shouldn't, because it's not my body and it's not what I'm feeling." This is a full admission on my part of others' right to their subjective experience. So the neat part is that I finally have the analog I needed to think about other people's subjective experiences of the world in general, and their emotional reactions to it. It doesn't even make sense for me to think, or tell someone, that they should or shouldn't be angry, sad, happy, resentful, etc. I don't know what it feels like to be them, and cannot. Neat! I have applied logic to my own attempts to apply logic where it doesn't belong.
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