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.
Wednesday, October 27, 2010
physical exams
they're hard. and useful. and infinitely complicated. the NYT summarized it better than I in the story they tell of Dr. Abraham Verghese:
http://www.nytimes.com/2010/10/12/health/12profile.html
http://www.nytimes.com/2010/10/12/health/12profile.html
Monday, June 28, 2010
The nurse's role
One of the most interesting things about my program is learning that nurses understand themselves and their role, and position themselves professionally in a way very different than, I think, most non-nurses, or at least non-medical professionals, understand. There's a whole lot more to it than "patient care." Or maybe I mean that "patient care" is a phrase that should be understood very broadly. I'd had no idea. I'd had vague notions that nursing was more about process and prevention, and possibly education, than medicine. But there's a lot more to it.
The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.
One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."
One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.
So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.
*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)
Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.
Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.
Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.
The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.
One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."
One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.
So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.
*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)
Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.
Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.
Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.
Wednesday, June 23, 2010
Nursing school is fun
It's been a week and a day, and I'm really enjoying myself. Just sayin'. This despite the fact that I have to get up early (I know, woe is me) and be at class early.
I'm taking 3 courses this quarter: pharmacology, pathophysiology, and "fundamentals of nursing." The first two are straight-up lecture-and-exam format (with lectures on one topic or the other for about 5.5 of our 8 hours in class on Mondays and Fridays), the third occurs in lecture, lab, and after the end of week two (this week), clinic. I'll devote a separate post to the awesomeness of my pharmacology textbook. There are information, concepts, and skills we're trying to learn and absorb coming at us from many directions, so there's a lot of straight-up homework as well as studying.
I've been mildly surprised and totally pleased that my textbooks from my prerequisite courses (Anatomy and Physiology and Microbiology), as well as my books from taking my nursing assistant certification (NAC) courses, have been helpful; I've referred to them lots while completing assignments and going over stuff that doesn't make sense from class notes. All of this stuff actually connects! :)
Last week we had our first 3 lab sessions, 4 hours each, 3-4 "classes" per session. We worked on blood pressure, temperature, bed baths, bed-making (for unoccupied and occupied beds), oral care ... really, mostly on things that NACs, not nurses, do in normal settings. I found my NAC training super useful for this, and realized the nurses instructing us haven't had to perform several of these skills in a long time, and as a result, hadn't thought through the chain of transmission (of pathogens)--at what point in these processes do you have to wash your hands and doff and don gloves again? It was, however, a much less scarily exact set of procedures than it was for my NAC training (aspiring NACs can fail their exam if they do crucial or trivial things in the wrong order), and I guess this is because nurses are allowed to think, and NACs aren't supposed to. Nonetheless, reading through the same procedures in my NAC books after re-learning this stuff was great, because I had a better idea of the do-what-when rationale underlying them. Better still, an actual order that someone thought through at some point, thoroughly enough to be worth including in a book for NACs, includes necessary materials and lots of picky details...since NACs should memorize, not think. :/ This isn't quite fair of me to say, however; at least one of my instructors said multiple times that in such-and-such a situation, she would ask her "nurses' aides," because they have a better idea about whatever it is.
We currently have many nursing instructors for lab because we're divided into our 6 clinical site groups (about 8 people per group), and for each lab, an instructor will teach one set of skills repeatedly, so we rotate through. I've noticed some funny linguistic usages and habits that most of our nursing instructors have. I'm no better at not asking questions in lab or lecture than I've ever been at any point in my life. In response, a few of the instructors will give a hand-wavey answer whether or not they have a real one, and follow that up with, "Does that make sense?" It's like they all learned that they're supposed to verbally check comprehension, but the question comes across more as a termination of inquiry than a genuine solicitation of admissions of confusion. They say "Does that make sense?" I hear, "It should make sense. If it doesn't add up to you, that's your problem, not a conflict in the various sources of information you've been given."
This is especially odd given that we're supposed to be developing "critical thinking skills." This is another buzzword we've heard several times. Rather than, "think about it," or explaining that critical thinking actually means analyzing new information in light of what you've previously understood, attempting to reconcile the two, and questioning discrepancies, we're told, "use your critical thinking skills." But in actuality, if our "critical thinking skills" lead us to ask questions at an inconvenient time, the response isn't ideal. (I am grateful that this seems to be more of a lab than a lecture issue.)
For example, one of the instructors was leading a practice on temperature taken at several different locations with several different instruments (did you know that a temporal temperature takes an average of temperatures across your forehead!?) and height and weight, and the metric to standard conversions that go along with those. I had to weigh my partner, so before I did so, I attempted to zero the scale. The weight that I would think should slide back and forth so the scale _would_ zero just didn't move. I looked all around the scale, was still at a loss, and finally asked the instructor. She tried to do the same thing I had, and when she got the same non-results, she said, "Weight is something you want to know as a baseline, so you can compare gains and losses over time, or know if there's sudden gain, which would be indicative of edema. In infants, small differences in weight matter, especially if you're administering meds, but in adults, a pound or two doesn't matter. Use your critical thinking skills! [Repeats all of the foregoing in a different order, then half of it again.] Does that make sense?"
While all of this did make sense, she had effectively denied that it was problematic that this scale seemingly could not be zeroed. She tried it, gave up, moved on, then gave me a spiel that indicated I shouldn't have tried to zero it (I guess). I'm hoping I'll get better at predicting which questions will stump/irritate the instructors, who will be our clinical supervisors, and just avoid those. Maybe at clinic there will be other people I can ask things of without causing frustration?
During our third lab session, after learning about "SBAR" (Situation-Background-Assessment-Recommendation), a communication protocol in medicine aimed at preventing medication errors through general improvement of communication, we did a simulation on one of these:
https://my.smccme.edu/ics/Institute_for_MFTE/Simulation_Lab/Meet_the_mannequins.jnz
(that's a random google hit)
Our Vital Sims mannequin is named Stu-the-Dude, and his compatriot Alex is currently across the country getting repaired, so we have a stand-in (lie-in?) named Miguel. In our lab, there's a "hospital room" with two beds, one for Stu, one for Miguel. They are hooked up to computers so that a person behind the 1-way glass wall of the lab can control their blood pressure, pulse and respiration rates, thus allowing students to be tested on taking the correct measurements of all these vital signs. The person at the controls can even talk into a microphone the speaker of which is in the Sims's mouth. After our introduction to Stu and Miguel, we were given 10 minutes or so to practice taking vitals on them, then our instructor Joanne (primary instructor of Fundamentals of Nursing, and head of the entire summer program, which is an absurd amount of coordination to do, bless her) told us we were going to do a simulation.
"As y'all are walking to clinic in the morning you see Stu riding his skateboard down the hill, lose control, and run into a stop sign. He's bleeding profusely from his femoral artery. You 4, leave the room. You 4 are on the scene. What do you do?"
Ack!
Four of us went into the lab to stand behind Julianne, our other F.O.N. instructor, as she tried to talk into the microphone like a skateboarder between moans in her unusually high-pitched, girly voice, while changing Stu's vitals. We watched through the one-way glass. The first team was given about 10 minutes, instructed to decide whether to tell 911 they needed an ambulance (A-car, I think it's called?) or paramedics. Then it was our turn, and we were supposedly there while the paramedics arrived, and had to make the transition, giving them necessary information.
Turns out Joanne was mostly interested in our ability to work as a team and get a job done, and we briefly discussed how that works. She said normally decisions happen because (1) there's an established hierarchy or (2) someone was first on the scene or (3) the person with the most confidence starts delegating. This was a little weird, though, since we're all new to each other and the program, and no one, I think, wants to be, or be perceived as, bossy or center-of-attention-ish, because one might run the risk of being disliked. Not useful in a program where one's cohort is so essential to one's survival.
After that brief discussion, Joanne had us do it again, reversing roles, and deciding ahead of time who would be in charge. Both groups performed better--of course, we knew what the situation would be ahead of time and had practice, as well.
This whole exercise was stressful and really, really fun. It reminded me of competing theories of language learning. Some instructors only want to give you problems that you have every tool to solve. Others want you to put things together, and attempt to reach beyond your level, and learn that way. I was in the latter camp, and I am excited that my instructors, and this program's philosophy, seem to (mostly) be in that camp, too.
I'm taking 3 courses this quarter: pharmacology, pathophysiology, and "fundamentals of nursing." The first two are straight-up lecture-and-exam format (with lectures on one topic or the other for about 5.5 of our 8 hours in class on Mondays and Fridays), the third occurs in lecture, lab, and after the end of week two (this week), clinic. I'll devote a separate post to the awesomeness of my pharmacology textbook. There are information, concepts, and skills we're trying to learn and absorb coming at us from many directions, so there's a lot of straight-up homework as well as studying.
I've been mildly surprised and totally pleased that my textbooks from my prerequisite courses (Anatomy and Physiology and Microbiology), as well as my books from taking my nursing assistant certification (NAC) courses, have been helpful; I've referred to them lots while completing assignments and going over stuff that doesn't make sense from class notes. All of this stuff actually connects! :)
Last week we had our first 3 lab sessions, 4 hours each, 3-4 "classes" per session. We worked on blood pressure, temperature, bed baths, bed-making (for unoccupied and occupied beds), oral care ... really, mostly on things that NACs, not nurses, do in normal settings. I found my NAC training super useful for this, and realized the nurses instructing us haven't had to perform several of these skills in a long time, and as a result, hadn't thought through the chain of transmission (of pathogens)--at what point in these processes do you have to wash your hands and doff and don gloves again? It was, however, a much less scarily exact set of procedures than it was for my NAC training (aspiring NACs can fail their exam if they do crucial or trivial things in the wrong order), and I guess this is because nurses are allowed to think, and NACs aren't supposed to. Nonetheless, reading through the same procedures in my NAC books after re-learning this stuff was great, because I had a better idea of the do-what-when rationale underlying them. Better still, an actual order that someone thought through at some point, thoroughly enough to be worth including in a book for NACs, includes necessary materials and lots of picky details...since NACs should memorize, not think. :/ This isn't quite fair of me to say, however; at least one of my instructors said multiple times that in such-and-such a situation, she would ask her "nurses' aides," because they have a better idea about whatever it is.
We currently have many nursing instructors for lab because we're divided into our 6 clinical site groups (about 8 people per group), and for each lab, an instructor will teach one set of skills repeatedly, so we rotate through. I've noticed some funny linguistic usages and habits that most of our nursing instructors have. I'm no better at not asking questions in lab or lecture than I've ever been at any point in my life. In response, a few of the instructors will give a hand-wavey answer whether or not they have a real one, and follow that up with, "Does that make sense?" It's like they all learned that they're supposed to verbally check comprehension, but the question comes across more as a termination of inquiry than a genuine solicitation of admissions of confusion. They say "Does that make sense?" I hear, "It should make sense. If it doesn't add up to you, that's your problem, not a conflict in the various sources of information you've been given."
This is especially odd given that we're supposed to be developing "critical thinking skills." This is another buzzword we've heard several times. Rather than, "think about it," or explaining that critical thinking actually means analyzing new information in light of what you've previously understood, attempting to reconcile the two, and questioning discrepancies, we're told, "use your critical thinking skills." But in actuality, if our "critical thinking skills" lead us to ask questions at an inconvenient time, the response isn't ideal. (I am grateful that this seems to be more of a lab than a lecture issue.)
For example, one of the instructors was leading a practice on temperature taken at several different locations with several different instruments (did you know that a temporal temperature takes an average of temperatures across your forehead!?) and height and weight, and the metric to standard conversions that go along with those. I had to weigh my partner, so before I did so, I attempted to zero the scale. The weight that I would think should slide back and forth so the scale _would_ zero just didn't move. I looked all around the scale, was still at a loss, and finally asked the instructor. She tried to do the same thing I had, and when she got the same non-results, she said, "Weight is something you want to know as a baseline, so you can compare gains and losses over time, or know if there's sudden gain, which would be indicative of edema. In infants, small differences in weight matter, especially if you're administering meds, but in adults, a pound or two doesn't matter. Use your critical thinking skills! [Repeats all of the foregoing in a different order, then half of it again.] Does that make sense?"
While all of this did make sense, she had effectively denied that it was problematic that this scale seemingly could not be zeroed. She tried it, gave up, moved on, then gave me a spiel that indicated I shouldn't have tried to zero it (I guess). I'm hoping I'll get better at predicting which questions will stump/irritate the instructors, who will be our clinical supervisors, and just avoid those. Maybe at clinic there will be other people I can ask things of without causing frustration?
During our third lab session, after learning about "SBAR" (Situation-Background-Assessment-Recommendation), a communication protocol in medicine aimed at preventing medication errors through general improvement of communication, we did a simulation on one of these:
https://my.smccme.edu/ics/Institute_for_MFTE/Simulation_Lab/Meet_the_mannequins.jnz
(that's a random google hit)
Our Vital Sims mannequin is named Stu-the-Dude, and his compatriot Alex is currently across the country getting repaired, so we have a stand-in (lie-in?) named Miguel. In our lab, there's a "hospital room" with two beds, one for Stu, one for Miguel. They are hooked up to computers so that a person behind the 1-way glass wall of the lab can control their blood pressure, pulse and respiration rates, thus allowing students to be tested on taking the correct measurements of all these vital signs. The person at the controls can even talk into a microphone the speaker of which is in the Sims's mouth. After our introduction to Stu and Miguel, we were given 10 minutes or so to practice taking vitals on them, then our instructor Joanne (primary instructor of Fundamentals of Nursing, and head of the entire summer program, which is an absurd amount of coordination to do, bless her) told us we were going to do a simulation.
"As y'all are walking to clinic in the morning you see Stu riding his skateboard down the hill, lose control, and run into a stop sign. He's bleeding profusely from his femoral artery. You 4, leave the room. You 4 are on the scene. What do you do?"
Ack!
Four of us went into the lab to stand behind Julianne, our other F.O.N. instructor, as she tried to talk into the microphone like a skateboarder between moans in her unusually high-pitched, girly voice, while changing Stu's vitals. We watched through the one-way glass. The first team was given about 10 minutes, instructed to decide whether to tell 911 they needed an ambulance (A-car, I think it's called?) or paramedics. Then it was our turn, and we were supposedly there while the paramedics arrived, and had to make the transition, giving them necessary information.
Turns out Joanne was mostly interested in our ability to work as a team and get a job done, and we briefly discussed how that works. She said normally decisions happen because (1) there's an established hierarchy or (2) someone was first on the scene or (3) the person with the most confidence starts delegating. This was a little weird, though, since we're all new to each other and the program, and no one, I think, wants to be, or be perceived as, bossy or center-of-attention-ish, because one might run the risk of being disliked. Not useful in a program where one's cohort is so essential to one's survival.
After that brief discussion, Joanne had us do it again, reversing roles, and deciding ahead of time who would be in charge. Both groups performed better--of course, we knew what the situation would be ahead of time and had practice, as well.
This whole exercise was stressful and really, really fun. It reminded me of competing theories of language learning. Some instructors only want to give you problems that you have every tool to solve. Others want you to put things together, and attempt to reach beyond your level, and learn that way. I was in the latter camp, and I am excited that my instructors, and this program's philosophy, seem to (mostly) be in that camp, too.
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