Guilty by omission?

If you haven't already picked up a theme among my blog entries, you soon will. I want us (every nurse possible) to work together. Now, when I say "work together" I am speaking in terms far beyond a shift or two...I mean really pull together as a profession and become a unified voice. There is no reason we cannot nor should not do this. Work in a rural area? A small clinic? A large university medical center? It doesn't matter. Neither our employer, our specific job description, nor or geographic location defines or limits our ability to interact with one another. Ever attend a national conference? If not, you should...at least once in your career...it is a wonderful opportunity.

Anyway, back to the topic of "omission". You can be guilty of not doing something just as easy as doing something. You can not give a medication or not perform an important procedure or intervention just as easily as you could actually do them. Being negligent due to omission can be a very important concept to consider in your practice. Do you pull up the blood administration policy every time you administer blood products? Sure, you may have administered it hundreds of times...but it only takes one incident to create a catastrophe. Don't get to comfortable in your routine...don't incorporate too many "workarounds", or shortcuts. There may be a time and place for them in some of your tasks, but when it comes to patient care and adhering to the 5 patient rights, there are no workarounds. You are busy...you have 10 things going on at once...you have 2 phone calls, 3 call lights, and a patient who wants to leave NOW. I get that. But the five minutes you save may be the most crucial five minutes of your shift...and you can't get those minutes back. Forget to raise a patient's head after restarting tube feeding because you are "busy"...the patient aspirates and quickly progresses into respiratory failure....then cardiac arrest...now you have a much larger problem on your hands. Maybe I am looking at this as "worst case scenario". Maybe. This is just an example, and this can happen to any one of us...and maybe something similar has. We have all been in similar situations...and if you haven't, more chances are you will at some point in your career. You can't get those minutes...those seconds...back. Just be careful.

Well, now that I have scared several of you from ever returning to work, let’s move on to another issue of "omission"....

Once again, lets "Google Earth" this topic out quite a bit, and gain a much broader view. In the recent issue of AACN Bold Voices (3(5), p. 22), AACN president Kristine Peterson speaks about our responsibility to seek out one another, use our available resources, and communicate with our policy makers (local and national), in order to ensure nursing's voice is heard at the table. Her article, "Will we let someone else answer?", is a great example of taking the initiative to pull our ranks together and do something. There is a wonderful quote by Goethe in this issue:

    

 Knowing is not enough; we must apply. Willing is not enough; we must do.

True. Very true. And this is what I mean by "guilty of omission": allowing policy to shape our practice instead of the other way around. We need to guide how policy is made. We need to be there when non-nurses and non-health-care-providers are at the table deciding what we can do, where we can do it, how we can do it, or even if we can do it. In the latest report from the Institute of Medicine, "The future of nursing: leading change, advancing health", released this past October, the IOM had four very direct recommendations:

• Nurses should practice to the full extent of their education, training, and licensure.
• Nurses should achieve higher levels of education and training. (Academic and other lifelong learning activities)
• Nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the US.
• Effective healthcare workforce planning and policy making require better data collection and an improved information infrastructure, particularly as it relates to nursing's contribution to care.

These were restated from Peterson's article, and I would strongly encourage you to take a look at this report for yourself. (If you don't feel like reading hundreds of pages, you can read the Executive Summary, which provides a nice overview. The IOM speaks to the nation, saying, "let nurses do what they are trained to do...help them achieve higher standards of excellence in their training...hear their voices...let them be involved in health care decisions"...in my opinion, anyway. But the IOM is saying this to nurses as well. We need to be proactive in our approach to policy and procedure formation. We need to make sure we are present at the table when these decisions are made...we cannot afford to let someone else dictate our practice. We have an incredibly rich and diverse body of knowledge within our profession. We have nursing scientists that work very hard to encourage improvements and innovations. It would be a shame if we did nothing, and let it all go to waste. It would be a shame if we were guilty of omission.

Take pride in what you are. Take responsibility for your practice, and for those who follow in your footsteps. Leave it better than you found it. Nurses are not generally a quite bunch, so I think this should not be as difficult as it sounds. The only barriers we have are those we place on ourselves.

Thank you.

Steve

Message of appreciation

Easter is a time of remembrance and thankfulness. For Christians around the world, it is a time to remember the persecution and crucifixion of Jesus, and his majestic rise from the tomb. As we remember and give thanks to Him, let us also remember one another. Let the symbolism Easter brings allow you go reflect on your own lives and practices.

I often think back to the day I was sitting in, what was to be, my final nursing class. At the time, I had no financial aid available, and no additional resources of my own to support my last semester of nursing school. As I stared at the clock, counting down the minutes I had remaining in the inevitable end of my education, I remember closing my eyes, desperately wishing for a resolution. I was a nervous wreck. About that time, the financial aid advisor pulled me out of class to tell me the news I had been dreading all day. She proceeded to inform me that there had been an "anonymous" contribution to my account, and that I could continue my final semester as planned. I was absolutely speechless (which if you know me is quite a feat). I was overcome with emotion. To this day, I do not know who made the contribution to my account that day, and I have never asked. I have also never forgotten that act of giving and faith. Although there is no direct comparison between the story of Jesus' selfless act for all of mankind, and the story I described above, I cannot help but be reminded of that day in my life. It was a selfless act of giving and placing faith in another that has changed my life. I have been truly blessed, and I will never forget that.

Since then, I vowed to myself that I will use that chance, that generous gift, to make a difference in nursing. I don't care where I'm at, or what I'm doing, I want to use my practice to help as many people as I can. If that means giving up an aspect of nursing that I hold dear to my heart, then I will do it, because I know I am doing what I am suppose to do. Whether it is being part of an initiative that has a direct impact on a large number of people, or simply one person, what I do does matter. One life can impact millions, that's why every person is important and should be afforded the opportunity to succeed.

So, I say to whomever you are...known only to me as "anonymous"...I send you my sincere appreciation and gratitude for this gift you have given me. And I thank all nurses everywhere for their service to mankind. You are truly appreciated.

Happy Easter.

Steve

Career options

One of the things I enjoy about nursing is the vast amount of career opportunities that exist. If you love kids, there's a job for you...if you enjoy the adrenaline rush of trauma, there's a job for you...or if you would rather stay out patient care altogether, yes, there's even a job for you. The point is, no matter what motivates you and brings you satisfaction and fulfillment, there is a nursing job out there for you, you just have to look.

However, the career path you are on may eventually lead you to new opportunities and challenges that you had never expected. Perhaps what you had planned in nursing is not what nursing had planned for you. Now some of us will spend their entire career in one area, and I think that is wonderful. Others may explore several areas before settling into a career path. And, after all, if you don't see a job you like, create one you do!

"What do nurses do?" It has grown increasingly more and more difficult to offer a concise answer. Some care directly for patients, some serve as leaders, some review medical records, some conduct research, and some teach the next generation of nurses. They can do all of these things because nursing prepares them for these positions. Nursing is so diverse that you can pretty much do anything you want just about anywhere you want.

I have enjoyed my nursing career so far. I have worked in several different capacities, and have learned a lot about nursing, and myself. Nursing has as much to offer you as you have to offer it. Think about that. Are you a member of a nursing organization, such as your state nurses association? Have you ever considered becoming involved in something that has a direct impact on your current, and future, practice? Being active in organizations such as the ANA allow nurses to have their voices heard when policymakers threaten to limit your professional practice, and thus, your career options. Anyway, something to think about.

So, in a nutshell, nursing = opportunity. Don't worry if you don't know what you want to do or where you want to work. Don't worry about not being happy in one particular area. Nursing provides a vast sea of opportunity. All you have to do is set sail and see where the winds of chance lead you.

Thank you.

Steve

I am a nurse

I am a nurse.

More specifically, I am a registered nurse. I completed prerequisite coursework, applied to nursing school, worked my butt off, graduated, passed the NCLEX-RN exam, and can rightfully call myself a "nurse". I earned that privilege and right, along with all of the responsibility that goes along with it. Yes, I am a nurse and very proud of it. And one thing that really chaps my rear is to hear someone proclaim themselves to be a nurse, or allow themself to be perceived as such, and no right to be identified as such. That just sends the wrong message about what a nurse is, and moreover, who we allow "nurses" to be.

For example, it bothers me that some school districts have "nurses" render care for their students, when these "nurses" may only be CNAs...if that. That's pretty bad. But what is even worse, in my opinion, are these receptionists and nursing aides or medical office assistants that identify themselves as a nurse. That, to me, has far reaching ethical and legal implications not only for the individual, but potentially for the physician and his/her practice. Some may think this is no big deal, it happens all the time, and there's no harm caused by such practices. Really? Try referring to yourself as a "doctor", or lead others to believe you are...see how far that goes. Not the same comparison, you may say? I beg to differ. There would be real ramifications if you were providing medical advice or offering diagnoses or treatment only a licensed physician could provide. The same is true for nursing. It is a "licensed" profession, which means it is regulated and must abide by legislated rules and regulations set forth by a governing body.

It's a public health and safety concern first and foremost. Giving medical, or nursing advice, in person or over the phone should only be done be persons with the education, training, and license to do such. To have a receptionist triage phone calls or phone in prescriptions is absolutely intolerable, and physicians should not knowing allow it, and nurses should not knowingly, or passively, allow it either. It's not legal because it's not safe. Period.

Switching gears a little, and climbing down from my soap box a step or two, I'd like to share my thoughts on what a "nurse" is to me.

After you move past the legal mumbo jumbo about who has the legal right to call him/herself a nurse, you get down to the actual practice of nursing, and what it entails. Nursing practice is based on the diad of science and art...kind of like left brain and right brain concepts. It is important to have both aspects because there are infinite scientific, statistical, and methodological factors that contribute to nursing practice. Likewise, there is an abundant amount of emotion, self-exploration, and creative ability that is unique to the profession. It is the overall concept of quantifying and qualifying the practice of "caring" that is challenging. How do you capture "emotional and spiritual connectedness" on paper, or in a graph? How can you explain the intuitive sensation that overwhelms you when a patient is about to crash? Why do we have theorists whose life work surrounds such concepts as "expanding consciousness" or "unitary human beings"? Because nursing is more than the sum of it's parts: we are part of something that is greater that all of us, yet we are each an essential component. Nursing is as abstract as it is concrete.

I went to nursing school to learn how to start IVs, administer medications, perform assessments, and provide patient care. And that is what differentiates us from the rest of the the healthcare team. We are taught the importance of practicing the blend of science and art each day. I can care for a train wreck of a patient, code the patient when the body gives out, using all the science and evidence I have learned to try and save a life. And when my efforts ultimately succumb to the will of a much higher power, I will walk over to the patient's window and open it a little when they expire. Is it because the literature tells me that it is best practice? Is it because there is a scientific foundation behind it? No. It's because I know that underneath the tubes and wires that remain after our science has proven its limitations, there is a human being with a spirit that must be treated with dignity and respect. By opening the window, I feel I am somehow facilitating the spirit's peaceful transition.   That's what sets us apart from the others: care of body and spirit.

No matter where I go, what I do or how I do it, I will always be a nurse, and the patient will always be my focus. I worked hard for that privilege, and so did you. Take pride in what you do, stand up for what is right, and keep the patient at the helm of what drives your practice.

Thank you.

Steve

Time-lapse perspective of your nursing career

There are some amazing time-lapse photography images out there. Images of faces, landscapes, astronomical and meteorological phenomena captivate audiences around the globe, in all types of culture. We seldem stop to appreciate "life" as it passes us by. One trip on the ride is all you get.

As I look at these photo compilations, I am amazed at the patience and perserverance the photographer has with his/her art. Each picture is designed to complement the rest, in sequence. The overall effect is that of transition and transformation through paced progression. The artist captures the beauty and individual significance of each still moment, and combines these unique traits to form a pattern that yields an overall completeness. And this is what I think of as I see nursing.

Apply this to your individual nursing practice. Take a few "mental snapshots" of a few significant (and perhaps some more typical) events which occurred during your time as a nurse. Perhaps you started when you entered nursing school, or maybe when you were much younger, pretending as a child. In either instance the concept is the same. Continue this until present day. Now begin playing these events, one by one. Can you see the transition and transformation? See your career change... your life change... as you sequence through these images? Then take it a step further, and add your dreams and goals from this point forward. It takes on an entirely different feel. Now, imagine any one of these events not occurring, or maybe happening with a different outcome. Does the overall effect change? Maybe, maybe not. I think it depends on the event and the point in your progression it occurs.

Now "Google Earth" that image back a bit, expanding the view of nursing as a whole. Think about your career in nursing, the changes you have seen, and apply this individually to the profession as a whole. Our collective practices have a transitional effect on the whole of nursing. What we do matters. The problem is that we don't often stop to think of our contributions as being those "still pictures" in the overall "time-lapse" progression of our profession. We are part of something much larger than ourselves, or even our careers; yet our contributions remain significant to the overall success and vitality of the profession for generations to come. We know what we know because of those generations before us, learning from their "snapshots", and placing a relative interpretation pertinent to our current practice. What we need to do next, then, is to continue that momentum (applying a bit of complexity science fundamentals along the way), and imagine what we would see.

We should appreciate the moments we have now, embrace our individual "collections of snapshots", and know that we are part of something great. Every patient we touch, every life we welcome into the world, and every one we help transition out of it, they all have one thing in common: we were there to extend our caring hearts and skillful hands in assistance. What you do matters. Don't ever forget that.

What seems insignificant, or even life-altering, throughout our years adds up to a unique "time-lapse" presentation of nursing, and how these moments can combine to create a beauty that we all should hope to view someday...and perhaps someday we will.

Maybe some of our grand theorists saw this view of nursing, and each chose a different way of describing it? You never know.

Never lose sight of your hopes and dreams. Sometimes they are the clearest pictures we will ever see.

Thank you.

Steve

Maintenance?

This morning at work, I had the pleasure of running into a couple of nurses I worked with several years ago. We worked nights together for years. During this time, one of these nurses had mentioned something to me that really made me upset..." night shift was considered 'maintenance'". WHAT?! Now, before I go on, these were not the words of this particular nurse, but of someone else...someone paid to come into an organization and "turn things around"...someone who had a "model" to share. I don't know if this person was a nurse or not, and to be honest, I really hope he/she was not. After all, what nurse would actually say something like that, and think it is truthful? Seriously?!

I worked nights for the majority of my nursing career thus far. I enjoyed the shift, I enjoyed the people, I enjoyed the patients. Not everyone is made for "nights", but I was, as are many, many others who choose this shift. Working nights is not a "stepping stone", and is most certainly not ever to be referred to as "just not day-shift material". What exactly is that suppose to mean? I have heard that a time or two. Let me tell you what these nurses, and many other ancillary providers do at night...the same thing as they would during the day, but with less resources. On nights, you have to think through situations, as you do not have doctors, midlevels, and many other practitioners readily available. We usually worked as a team...a team...and used one another as first-line resources before making those calls at night...it's just what you do. Now, I have worked days as well, and I can say that some places may be better than others in regard to "teamwork". I can say this: in my opinion, the night shift workers tended to exhibit better "team" characteristics and better cohesion as a group. Not saying everyone was perfect, but we all never hesitated to lend a hand. I cannot say the same for day shift...as a whole. I don't want to create a divide here...I do not want to lead you to believe that one is "superior" to the other in any way. I am saying that I have respect for the work accomplished during each shift...along the continuum of care, and that each shift displayed differing team dynamics. That is all.

To hear someone refer to night shift as "maintenance" is pretty ridiculous, and could not be farther from the truth. Night shift does not just sit around, watching gauges, tweaking knobs, and waiting for the "real" workers to get there. The same skills, education, training, and patient-focused care goes on when the "lights are off". Sure, patients may be sleeping...but some are crashing, some are confused and trying very hard to get out of bed, some are having babies, and some are babies that have no concept of day or night. The point is, we should not discount our colleagues simply due to the hours worked. There are some damn fine nurses on each shift, and each one an extremely valuable part of the continuum of care, which we should be focused on.

We all have stories and anecdotes about each shift...and how "night shift did this" and "day shift did that". I have been guilty of this too, I admit it. But I have moved past that. We all have things to get over...so lets just do it. Get over ourselves...our egos...our pride, and put the focus back, once again, on the patient. We all make mistakes, that is a fact. We are humans, and by that very fact alone, are not infallable. Care that is safe, equitable, efficient, effective, timely, and patient-focused (as discussed by the Institutes of Medicine) is a priority for every nurse (or at least it should be).

Sunlight doesn't decide whether or not you are a competent nurse...you do.

Oh, and to the two nurses (who shall remain nameless, but you know who you are), it was nice to see you again, and "thanks for all you do!"  {;-)

Thank you.

Steve

Certification...what's in it for me?

One thing that I am very much in favor of is advanced certification. If you have taken the time, and energy, to pursue certification, it speaks volumes about you. It says that you have decided that time spent increasing your knowledge about a particular aspect of nursing is important to you, and that overall, delivering safe, effective, quality care is too. If you are a certified nurse, you understand the feeling of satisfaction, accomplishment, and the boost to your self esteem you received after passing your exam. It's a great feeling to know that you have put yourself out there, and succeeded in something far too few will ever try.

But is it for everyone? Probably not. And that's okay. "To each, his own." But what about you? What are your thoughts on advanced certification in your specialty?(If there is one, anyway.)

It was the hardest test I have ever taken; boards were nothing compared to my certifying exam. That is where the pride and honor come from. If it were easy, what significance would it have? Very little, if any. Becoming a certified nurse doesn't make you "smarter" or "better" than a non-certified nurse. It simply says that you have challenged yourself to. Level of expertise in your field, and that you are dedicated to delivering the best care you can, based on the advanced knowledge gained by achieving and maintaining your certification. Patients may never know who is and isn't certified, but wouldn't it be nice if they did? Maybe some would argue that patients may feel that ALL nurses should be certified. And that they may feel that care from a non-certified nurse may be, somehow, substandard. I think it's all how you approach the conversation.

To me, being certified was a personal choice, as much it was a professional one. What have you got to lose? You fell off your bike a few times, but you still kept on trying, didn't you? Or maybe you just said "forget it!" and walked away. Think about what you would have missed. The main issues I find with pursuing certification are the time and financial costs involved. But please know there is help out there! Surely you didn't learn to ride a bike, or to swim without help? Seek and ye shall find.

What about compensation? "Will I get paid more for being certified?" That depends on your facility. But when you receive raises, do you begin practing better only when you receive financial gain? I doubt that. Money does not (or at least it should not) dictate your standard of practice. Sure, it's nice to receive a little extra for your hard work and dedication, but then again, "why are you a nurse?"

Remember, nursing has been deemed over and over again as the most "trusted" profession. Think about that. That's huge! Trust doesn't come lightly, in fact, it bears quite a responsibility. We are not the "good enough" profession, or the "status quo" profession. No, we are far more than that, and we owe it to our patients and ourselves to be equipped with the best information we can, and hold ourselves to a higher standard than what is required. Do some research, talk to your certified colleagues...and if no one is certified, be the first one!

A few links to get you started:
ABNS position statement for certification
ANCC website
Wikipedia list of certifications*
* I typically steer away from wikipedia, as it is not the best source of information, but it does at least point the way for further review. Also, please note that among the many certifications available, there are several such as "TNCC" which are not "specialty certifications", more like "practice certificates", and although valuable, are not concidered "valid" specialty nursing certifications.

Thank you.

Steve

Turning points

There are certain points in your life, and your career, that have a significant impact on you personally and/or professionally. Remember the first time you had a patient die? Or how about a time when you made an impact on a patient, and helped them overcome a struggle they had? Remember when you held your child for the first time? Tell me that didn't change your life forever! Each of us has these moments in our life. They are who we are and why we are where we are today.

We have to accept what happens to us, because we can't really control it. About the only thing we can control is how we respond...how we interact. You can't make your patient's colostomy bag smell any better...but you can refrain from making that "sweet-mother-of-pearl-what-died" face, and act like you notice nothing. We can work alongside someone who just likes to swing on our very last nerve, and choose to ignore their efforts to elicit a response. You see, WE are in control of us...even if we feel like we aren't. I'm not saying pretend the colostomy smells like fresh baked cinnamon rolls, or that the person next to you is your BFF. These things are what they are. Just let them be, and carry on about your day. You have things to do, and these are but small pieces of gravel in a long unpaved road that is your day...and your life.

I remember the first time I had a patient pass on in the NICU. It was devastating. I did my best to hold back my tears. The baby's father- who was a very large "prize-fighter-looking" guy was an emotional wreck, reduced to the very essence of sadness and grief. He was crying for the both of us. I'm not saying what I did was the "right thing" to do...I know many others would have been a mess. But I chose to remain as calm as I could, and offer him and his wife all of the support I could...allowing them this private moment to hold their baby, without having to share this with me. That was my choice. That was a turning point.

Having kids makes as different...it just does. There is no other love on this Earth that compares to the love you have for your child. To see a parent grieve over the loss of their own child is heart wrenching, and I cannot even begin to imagine the pain that they feel. I know, for them, that will be a turning point. The patient who comes very close to death, experiencing powerlessness and loss of hope, can persevere and live to appreciate life a little more afterward. That is a turning point for them.

What about professionally? What have been your turning points? My time spent in the NICU was definitely one of mine. That is a whole different world all in its own. My thoughts about caring, sharing, learning, and leading have been shaped by certain events and people through the years. I have never forgotten one man who taught me that having a positive outlook is my choice, and moreover, why wouldn't I have one? He used the comparison of driving a Pinto or a Ferrari. He asked me, "if you could choose either car, which one would you drive?" Of course, I said Pinto! (just kidding, I went for the Ferrari...) He said, "OK, so when someone asks 'how are you today?', what do you say...'okay' or do you say 'GREAT!'" I have never forgotten that. Those who know me will understand this story, because every time someone asks me how I am doing, my response is either "great!" or the ever popular "fantastic!" Why would you have a negative attitude, when you could just-as-easily have a positive one? It isn't anyone else's fault (or problem) that you may be having a bad day...you don't need to spread that kind of energy around.

I do firmly believe that everything happens for a reason...even if it seems pointless at the moment. Change is inevitable, and we must embrace it, because there is no use in resisting...it will consume all of your energy, only it will happen much faster! You don't have to like it, but you must accept it for what it is...change. It goes both ways, good and bad. I can say that I have failed at a lot of things in my life, and I have learned a lot too. I appreciate who I am and what I do now more than ever. And I appreciate all of the people I work with too. It's not easy being a nurse, and perhaps that's why I love it, and respect it. Trying to influence change in nursing is like attempting to steer the Titanic with a spoon. It may seem impossible, but you will never know until you try. And when you get knocked down, sit there for a minute...think about what happened...get back up on your two feet...put on a big smile and say, "thank you, may I have another!?!"

You don't get to control what life brings you. You don't get to control how people treat you.

When your life is at a turning point, you will definitely know it. You will find yourself re-evaluating your inner self, your career, your hopes and dreams...everything. And when you are at that crossroads, look carefully at your choices...choose the unpaved road...full of bumps and uneven surfaces. That is where you will find adventure and experience true discovery (hopefully of your self). And remember...

Have a GREAT day!

Thank you.

Steve

Get Involved

I am a member of my state's Bar Association. I'm not an attorney, but I maintain a "paralegal" membership, especially because I am a legal nurse consultant. The membership provides me with access to legal interpretations of important matters that could (and do) affect my professional practice, and my personal life.

Every year, my bar association organizes a health law institute, put on by the health law section of the bar association. I try to attend this every chance I can...and as a matter of fact, I was able to attend this year's session yesterday.

Of course, there is a great deal that does not apply directly to me, as a nurse. However it is very valuable to spend the day in a room full of health law attorneys, discussing state and federal law that has a potential to affect my practice. It should be no surprise that this year one of the topics covered was the Affordable Care Act, and what that means to health law. Additional time was spent talking about Accountable Care Organizations (ACOs). I won't go into these issues here, as they would require much more time than I have...and besides, I can't say that I completely understand them myself right now. But what I can say is that I took that important step toward learning about these things. No matter what your role is in nursing: staff nurse, clinic nurse, school nurse, you are all nurses. We all have a professional responsibility to make ourselves aware of anything that might impact our practice, and our ability to care for patients. You don't want someone who has no clue about nursing to make policies and procedures that may negatively impact your licensure or ability to practice to fullest extent of your education. The old saying goes, "you don't know what you have until it's gone."

So I ask each one of you to spend a few minutes reading about health care reform, state and federal legislation proposals, and anything else that may impact your practice. Trust me, putting your head in the sand is neither acceptable, nor responsible. Your state nurses association (if you have one) is an excellent place to start. If you don't have one, visit the American Nurses Association's website for a good list of resources.

I have been guilty of not really understanding the importance of bring represented legally and politically when these issues are being debated in the legislature. Recently, however, I have gained a whole new respect for the importance of this process, and how dangerously close we can come to not having representation when decisions are made on our behalf. But not everyone wants to be involved at that level. If you want to keep it "closer to home", then get involved at the level of your employer. Join a committee or perhaps a journal club; anything that will get you more involved in your practice and your profession.

We are where we are, professionally, because of those nurses before us. We stand on the shoulders of giants. Whose shoulders will support the next generation of nurses? We cannot afford to stagnate our progress, and thereby reducing nursing to a "job", instead of a profession. Do what's right; do what's responsible.

Thank you.

Steve

Physician Relations and Communication

Probably one of the most feared aspects of becoming a new nurse is "calling the doctor". It's not easy to do your first time or two, but you eventually learn...sometimes the hard way...but you do learn. Some physicians want very detailed information, some want a very brief synopsis of events, some like to be called with updates (although I haven't met too many of these), and some don't want to be bothered with anything, it seems. We learn by trial and error, appreciating personality types as much as anything else. But why is this? You don't see too many physicians fretting over calling a nurse. None of them try to carry out "cluster calls", whereby questions on several patients from several practitioners are carried out during one phone call. I have yet to hear, "sorry to bother you, nurse..." Now I'm not saying their roles are not important, and their stress level isn't high, but let's face it, we are all in the same boat. Why can one group be allowed to continually "rock" it, without regard for who may fall overboard, while the other dare not even think of "making waves". It's because we have set a double standard, like it or not. The nurse's role has been of the "follower of 'orders'", responding simply with "yes doctor, right away."

There is a time and place for everything. Perhaps in the early days of nursing, when we were attempting to establish ourselves as a profession, and when physicians were the ones training nurses, this is how things were. As our profession has grown, and the field of nursing science has developed, we have yet to break away from the, "at-your-service assistant". Nurses have a very important function within healthcare: to care for patients. Physicians do too. However, it is how we do this, or under what guidelines we practice that makes all the difference. Nurses are not trained as physicians, and physicians are not trained as nurses. Simple enough. Simple enough, right? Well, why do we, as nurses, feel that it is ok for us to be treated as "physician servants", rather than professionals? Now I realize I am making several generalizations here, but I know that many nurses can relate to these issues. I can almost guarantee you that you have witnessed more unpleasant interactions from physician to nurse, than from nurse to physician. We tolerate it because we are indoctrined to do so. It is the unwritten rule.

But why must this be tolerated? Why must we allow this to continue?

Because we want to keep our jobs? Because it's just the way it works? Really? Is it "working"? I'm afraid not.

I am not at all bashing physicians. I have the utmost respect for their education, training, and responsibility to the patient. They are one of the most important components of the healthcare system...but not the most important. I just don't believe it is very becoming of a "profession" to tolerate this sort of interpersonal/interprofessional communication. Ever heard of transference: going home to yell at your family because you were treated in a similar manner at work all day? Well it seems to me that this is very similar to what we have been reduced to. Just look at the phrase "nurses eat their young." Why is that? For a "caring" and "nurturing" profession to make an exception for one of their own? Why do we do that? Why on earth would we allow that? Physicians take their frustrations out on you, so you do the same to the new nurses just because you were treated that way...or perhaps so they will become as callused as you?

There is a great opportunity to be seized when a nurse and physician can communicate effectively and professionally. We have a great deal to learn from one another. When we take the patient out of the conversation, we lose sight of our purpose. We let circumstances and emotions drive our conversations. We should expect to be treated with the same respect and dignity that we extend to others. If we are being berated in a patient care area, in front of family and colleagues, we should respectfully decline to continue the conversation in such a manner. Mistakes happen. Things can be overlooked. Blame is so much easier to give than accept. Perhaps the order was delayed because it had taken 4 nurses to interpret the penmanship, and only then a "best guess" was initiated. None of them dared call to clarify the order...it is just not how that situation is handled. We stop what we are doing to interrupt others to burden them with the task of interpretation. Physicians write constantly all day. I get that. Sometimes handwriting can get a bit sloppy. I get that too. What I don't get is why we do not do what is best for patient safety, and call for clarification. Why? Because we do not want to get our "butts chewed off" over the phone for bothering the doctor for something so "stupid". Really? If your child were the one about to receive someone's "best guess" of an order...or did not receive something because of the same, would you still agree that it is best not to bother the doctor for fear of being yelled at? No way! We all have a duty to the patient. Get that? The patient.

We can all play nice in the sandbox. I have experienced both sides of the conversation...good and bad. But each time a negative interaction took place, I had to reflect on my part of the situation. Did I have the necessary information at hand before communicating with the physician? Did I examine the situation carefully before hand...using critical thinking skills before contacting the doctor? (That's right, thinking.) Perhaps I am the one to blame a few times. I accept the fact that to be the 50th caller of the day, about an issue that did not really necessitate interrupting the physician during his/her busy schedule, may result in a less-than-optimal verbal exchange. I cannot accept being the 50th caller to interrupt the physician for a situation that can only be rectified by a physician, and be the object of frustration and annoyance. Sorry, Charlie, that's my job, and I would do it again in a split second.

We have the opportunity to gain great favor with physicians by following orders as best as we can, and within the scope of our practice. We can do our best to anticipate patient (and physician) needs, and take care of as many as possible with the least amount of "pestering". We can pull ourselves together, get our heads on straight, put our efforts toward practicing professional nursing, and keep the patient's health and safety as our priority. We can also expect to be treated as professionals. We are not "lower on the food chain", unless we allow ourselves to be. We are not "equals" by credentials, but we are by our service to the patient.

I have the opportunity to interact with many physicians throughout my workday. I enjoy the opportunities I have to help educate them on my role and how they can improve their work product. I don't tell them how they should practice medicine. I don't tell them how to do anything. I simply offer suggestions for improving their documentation. That's it. I get to build rapport with the physicians, letting them see what nurses can do, what we can offer, and more importantly, how we can really be of assistance to them. We are there to support them and help them carry out their professional duties to the patient. We are their eyes and ears when they are not at the bedside. We must be effective in our thinking and our communication abilities if we ever hope to raise the nursing profession to the level it should be within healthcare. We have a great deal to learn from one another. Our roles are not interchangeable, but our professional expectations should be.

Thank you.

Steve

Where are we headed?

I often wonder that. Where are we headed...heck, where am I headed! I know my destination, but I have decided not to plan the journey in its entirety. What fun is that?! I want to be at (or near) the leading edge. That term is used in many different contexts, including aviation when describing dynamics of flight surfaces, and in meteorology when describing weather patterns. Both seem very different at first glance, but upon closer inspection, become much more intimately related.

Leading edges of aircraft wings, for example are the point at which the air strikes the wing, causing it to flow across the top and bottom surfaces and varying speeds, resulting in "lift". The leading edges of storms are not where the problem lies, per se: it is behind this leading edge where the turbulence occurs. In both instances, undisturbed airflow is suddenly changed and altered, creating various patterns of behavior, some predictable, some not. What happens behind the leading edge in either event can be described as "conflict" and "chaos", to at least some extent. Now, not all conflict and chaos is bad...an airplane gains altitude, and thus flight, from the "conflict" of air speed and pressure changes behind the leading edge of the wing. In a thunderstorm, the leading edge of the air mass interacts with the opposing air mass, and creates turbulence and "chaos" as well. This can result in negative phenomena, including tornadoes and other severe weather.

In either instance, the "order" that was once perceived was suddenly disrupted, causing "dis-order" and a certain degree of unpredictability. The moment of chaos and uncertainty created by the leading edges resulted in changes in patterns, relationships, and overall direction. Was this necessarily a negative occurrence? Who knows. Must all conflict connote negatively?

So the question I might pose next is, "What is the purpose of flight: destination or disruption?" Can one be achieved without the other? (Man, it's getting pretty deep around here... Okay, so enough with the philosophical rambling.) But my point is this: without the necessary disruption of stability and predictability, how could we ever truly embrace our intended purpose and move significantly closer to our destination?

Nursing has come a long way...with Florence Nightingale at its most recent leading edge. She answered her calling from God to pursue this career, in great opposition from the intentions her mother had for her. Her life was to be spent being a wife and mother. (A stable, predictable life). Instead, Nightingale pursued the unknown, guided only by her deep desire to do God's work. She accomplished many wonderful things in her career as a nurse. She cared for the sick, making detailed observations along the way. Her dedication to the role led not only to cleaner, healthier conditions for the soldiers of the Crimean war, but eventually for an entire nation. She acted locally, acting firmly for what she believed in, and took it "global", through her many influential contacts she had made over the years. Sure, she created turmoil behind her. Not everyone was pleased with her thoughts and actions, but eventually her efforts paid off, and her driving force at the leading edge of nursing gave flight to the profession, and allowed it to soar to heights she had never anticipated.

That's where I want to be. I want to be at the edge of chaos, where effective innovation and discovery takes place. With uncertainty and risk comes the potential for failure....but also for success never before imagined. And that is the awesome beauty behind complexity science...you can not predict the impact one seemingly small, insignificant force can have on the whole. Take a step outside your comfort zone. Stretch your boundaries a little. Embrace the possibility of failure, because only then can you embrace that of success.

I want to improve the art, science, philosophy, and purpose of nursing. What is it? I have no idea, to be honest. But that isn't going to stop me. I know my destination, I have started my journey. I know where I'm headed...just don't have a clue in the world how I am going to get there...and I couldn't be more excited.

Where are you going?

Where are we going?

I appreciate your time.

Steve

"Start local and take it global"

Sounds a bit "motivational poster" -ish, I know, but true nonetheless. I kinda like it. Most all of us have had a course in nursing theory, where we sat, at least initially, with eyes glazed over and the attention spans of adolescent gnats. It was hard to take in all that stuff that appeared to have no bearing, no relation to anything we were to do "out there" as nurses. Or so it seemed.

I have to admit, I, too, was guilty of the blank stare now and then. As a guy, I really had no real knowledge of what nursing was all about. I thought it was a great career choice to get started in health care, make some money, gain some experience, and move on into medical school someday. Sure, I had seen all the wonderful, obviously true-to-life television programs depicting what nurses do on a day-to-day basis. Then I sat through nursing theory....

Boy was I misled! (Shocking, I know). We talked about Florence Nightingale, Sister Roy, Martha Rogers, Margaret Newman, Hildegard Peplau, among many others. We talked about what nursing was all about, how it has developed over time, and how "caring science" formed the foundation of nursing. Each theorist had her own take on the concepts of nurse, person, caring, environment, and health. Some were grounded in practice, while others never even attempted to touch the ground at all...all you Rogerian scholars know what I'm talking about.... However, no matter what you say about them, they all made great strides to put their thoughts and ideas out there to the wolves, and stood their ground. They took great pride in their profession. They were nurses. They were not content on what nursing was...but on what it should be and could be.

All that "touchy-feely" stuff was a bit fluffy for my taste...at least initially. Why did I have to sit through this crap about the universe and interpersonal relationships??? Get me out there on the floor, starting IVs, running codes, holding pressure on gushing wounds, shouting "STAT!" every other word... THAT was what nurses do! Right? Let's get past the potpourri of emotions and get to the action! Well, it turns out that if you want to be a monkey with a few technical skills, then it sounds like you have a great job description. However, if you want to be a nurse, then you better shut your yapper and open your ears. You've got a lot to learn.

It is amazing what people can do; especially when they don't even know they are doing it. I remember taking care of my first stroke patient (and yes, I do remember her name). I remember trying to put myself in her shoes...looking through her eyes. She couldn't move half of her body. She couldn't speak. But she could look at you with eyes that told more than her mouth could ever articulate. I remember that feeling of empathy, sadness, and personal struggle. It was the first time I remember connecting with my patient. What an impact one person can have. And she didn't even know. Or then again, maybe she did. Who am I to say?

One person can influence millions. One person can change the way governments rise to power (or crumble to ashes). One person can change the way we live, think, and relate to one another. These people are not just born into influential positions; they create them. One widely recognized example of how one person can change the world (literally and figuratively) is Facebook creator Mark Zuckerberg. Just step back and look around you. If you do not "facebook", then I will bet you that you know many that do. Think of the impact...unintentional impact...that this man has had on how we communicate with one another. Look how Facebook influenced the political activities in Egypt. Think about how one person's "local" idea became "global".

One thing that I have become increasingly more interested in is "complexity science" and "complex adaptive systems". That, in itself, is an entire blog on its own...I will not go into it here. Yet I will pose that if you do not know what this is, you should do a bit of reading on the topic. It builds on concepts such as chaos theory and innovation. I think that the great thinkers in nursing understand this idea, and they will acknowledge the tremendous impact one, seemingly isolate and unrelated stimulus can have upon complex systems and populations.

Let us all be butterflies, flapping our wings...creating the small changes that may later alter much larger phenomena around the world. We are the essential part of those small, initial forces that may later develop into true professional innovation, redirection, and positive growth, affecting individuals and communities we will never know.

Thank you.

Steve