Fast Food Nation: When Customer Service Competes with Patient Safety

by jparadisi

Drive-Thru Health Care by jparadisi

Calculating chemotherapy doses by surface area (m2) or kilograms was a smooth transition for me, a former pediatric intensive care nurse. In pediatrics, every medication, even acetaminophen, is dosed by weight. Tailoring chemotherapy doses to a patient’s weight was already a familiar concept; likewise dose reduction or withholding treatment altogether based on the patient’s lab values and assessment.

It’s a rare patient, however, who understands that her chemotherapy is prepared to order, not mixed ahead of time and awaiting her arrival, as if it’s fast-food made for the masses, preserved under a warming lamp.

This doesn’t matter as much if the patient receives his or her care in the hospital, but sometimes it creates unrealistic expectations in ambulatory oncology clinics. Somewhere along the line, good customer service has become confused with fast service, resulting in more and more patients with unrealistic expectations for their appointments.

It was one of those shifts when appointments backed up. Several factors contributed: Harsh weather conditions meant some patients arrived either late or too early for their appointments. The rapidly approaching holidays caused schedule changes for some patients. Of course, there were the normal, garden-variety delays: lab values requiring attention and patient veins that refused to accommodate IV catheters, etc.

Throughout the shift patients asked, “What’s the holdup?” Each time I thanked them for their patience, and validated the importance of their time. All shift long I explained, “One of the difficulties is that administering chemotherapy is not like making fast-food. Each treatment is made to order, measured against your lab values and tolerance. Our most important service is guarding your safety.” The explanation was received well, refocusing expectations on patient safety. Patients expressed appreciation for their nurses, oncologists, and pharmacists watching out for them.

The shift reminded me of a statement made by my husband, “Health care is neither inexpensive nor convenient,” and another one I heard a celebrity say on TV, “There’s never enough time to do things right the first time, but there always seems to be time to fix the mistakes later.”

Delivering prompt care is part of customer service, and as nurses, we should endeavor to keep appointments on schedule. However, our most important responsibility is patient safety.

How do you help patients keep their expectations regarding their care realistic?

Nurses & Doctors: Make Appreciation Reciprocal

artist: jparadisi

artist: jparadisi

Few life-threatening or terminal diseases present themselves in otherwise healthy, alert, and charming hosts the way cancer does.

From the get-go, oncologists are not only captain of the ship; they hoist life preservers in the form of treatment to patients drowning in waves of shock after a cancer diagnosis.

In my opinion, oncologists’ hearts closely resemble those of nurses. This is attributed to the fact that although oncologists do not spend the same quantity of time with patients as nurses do, the quality of the time they spend is intense. They often form relationships with patients over years. It’s common for an oncologist to know close members of their patient’s family, also like nurses.

During my last episode of possible (it wasn’t) recurrence, I experienced this truth.

My oncologist and I share a professional relationship. One of the reasons he’s my oncologist is because I know he’s good at what he does. My husband likes him, too. They share an easy communication, which is another reason for my choice. If/when cancer recurs, I know they will cooperate on my care, freeing me to be the patient, not the nurse. This arrangement brings me peace of mind.

Anyway, I had suspicious symptoms, which landed me face down in an MRI. My appointment to receive the MRI results was scheduled at end of a workday for my oncologist.

David accompanied me. Dr. My Choice entered the exam room holding the films, clipping them to the light box.

“I haven’t looked at these yet,” he explained. “I thought we could see them at the same time.”

It hit me in a flash: Dr. My Choice likes us too. He is about to find out if he will tell a nurse he enjoys working with, and her husband, whether or not her cancer has recurred.

Snap! What have I done to him?

Fortunately, the films revealed I am still cancer free. The look of relief on Dr. My Choice’s face nearly equaled David’s.

Oncologists, (doctors) have feelings, too. This knowledge affects the professional relationships of nursing practice in the following ways:

  • When questioning an order, assume the doctor has good intentions toward his or her patient, same as you.
  • Avoid framing questions to a doctor with your personal inferences, such as opinions of whether or not the physician is “good” or “bad.”
  • Consider that doctors suffer from work overload, and burn out, as do nurses.
  • Remember: Being part of a team is catching one another when we fall. No one is on top of his or her game every time.
  • Protect the Rock Star Doctor (every unit has one) by double-checking their orders the same as you do for any other physician. Don’t let them fall to earth because you were not diligent in providing a safety net for their patients.

Education is the tool of our trade. It is our demeanor, which makes us professionals.

Helping Families Manage End of Life Pain at Home

In the oncology infusion clinic, sometimes I provide care for patients whose pain medication management is not under their control.

Typically, this patient has rapid disease progression, almost always with metastasis to the spine. They are easily identified by their need of mobility assistance. They are in pain even while lying in bed. Often they talk to you with their eyes closed. They are too sick to speak for themselves.

Also typically, a family member accompanies them. That person can recite by rote not only the name of all the patient’s prescribed medications, but the doses, and when they were last given. The caregiver provides a detailed report of the patient’s diet, stools, and urinary output. Glancing at the patient, I see he or she is freshly bathed, and dressed in clean clothes. Obviously they are well cared for.

Next, I assess for the fifth vital sign: pain. The patient’s body language prepares me for a high number. I am not surprised when they report an eight out of 10 or greater. I see on the home medication list that their oncologist has prescribed both a long-acting pain medication and a short-acting one for breakthrough pain.

I ask, “When did the patient last have pain medication?” The caregiver answers, “Last night.” I ask,  “Why didn’t patient didn’t have a dose in the morning before their appointment?” The answer is something like, “He needs to walk more.” “He doesn’t eat enough when he takes pain meds.” “I didn’t think he needed it,” and a long list more. Family members withholding a cancer patient’s pain medication are a common problem confronting hospice nurses.¹

It is my experience that when pointing out to this archetypical caregiver that their loved one is in pain, they begin crying. They almost always have the vial of long-acting pain medication in their purse or pocket. I get an order from the oncologist, and together, we treat our patient for pain.

I explain that the bone pain will not go away, it will only worsen. The patient will need more pain medication, not less. Then we discuss loss and grief, and how painful the feelings are. The caregiver sees their loved one floating away on a cloud of analgesics, and illogically thinks that withholding narcotics will keep them here longer. There may be other reasons the caregiver withholds pain medication, as well.²

How can an oncology nurse help this caregiver?

  • Provide a safe environment for the caregiver to talk about their grief.
  • Use the word “medications” when describing opioids and narcotics, instead of the word “drugs,” which has a negative connotation when associated with these necessary tools of pain management.
  • Is the patient eligible for home hospice care, which provides support and respite for the caregiver? If yes, provide the necessary referrals.

Encourage the caregiver to be brave. Appropriately treating their loved one’s cancer pain is a declaration of love.

And I say a little prayer for all of us.

Have you had similar experiences in your practice?

References:

http://www.medscape.com/viewarticle/557072
http://www.cancer.org/cancer/news/expertvoices/post/2012/05/07/just-say-no-to-pain-drugs.aspx

Alopecia And The Pirate

As I write this post, some scientists are searching for ways to prevent male baldness through genetic manipulation. Others are conducting similar research to cure cancer. Is hair really as significant a part of our identity as we are sold to believe?

My hair began falling out the 14th day after the first chemotherapy infusion. In preparation, I bought a wig, styled and colored the same as my real hair. Like a feral animal, it perched on its stand, awaiting an opportunity.

When I saw the first ungodly huge handful of fallen hair I was too stunned to cry. Instead, I mumbled, “F***,” repeatedly, like a demented chicken.

It didn’t fall out all at once. Each morning for a week, I’d step out of the shower holding gobs of hair in my hands to prevent clogging the drain. After blow-drying what was left on my head, I’d take a pair of manicure scissors, like a naughty three-year-old, and try to even it out and disguise the bald patches. When I no longer could, a coworker’s husband shaved my head while she collected the locks, tying them into small bundles with blue satin ribbons. Image

After a time, I stopped wearing the wig. I preferred to cover my baldness with a red bandana, pirate style.

It was summertime, and I was at downtown Portland’s Pioneer Square, when a young man wearing a pirate’s black hat, white blouse with buckskin laces, black britches, and boots approached me. He clutched an authentic-looking sword. This was years before Johnny Depp made pirates sexy. Despite fatigue and chemo brain, I understood: “Oh, no, this guy sees my bandana. Pirate guy thinks he’s found pirate girl.” There was no place to run.

He spoke to me. “Ahoy! Me beauty, how art thee this fine afternoon?”

“I art fine, thanks,” I replied. “Why are you dressed like a pirate? Is that sword real?”

“Aye.”

He belonged to a club, of sorts, of people who dress like pirates and act out sword fights. I puzzled over what he wanted until he reached into his blouse and pulled up a goddess pendant dangling from a leather thong around his neck. He brought the goddess to his lips, kissed it, and then pointed to the carved turquoise goddess I had worn on a silver chain since my diagnosis.

“My fair Muse hails from Hungary, where she symbolized the female spirit of war and led her people to victory. I see you wear the Goddess yourself.” Doffing his hat, he bowed before swaggering back into the crowd.

He had approached because of the necklace, not the bandana. He hadn’t noticed that I was bald — or had he? Did I just have an encounter with an eccentric or a very kind man dressed as a pirate offering encouragement?

He left me smiling. There is more to each of us than what we look like.

This post was originally published by TheONC.

Nurses: Telling Our Stories Can Help Others

In art school, I once presented a painting entitled, “Recuerdo (I Remember)” for class critique. The painting was inspired by my experiences as a pediatric intensive care nurse.

The image sparked an enthusiastic discussion among fellow students, during which I answered many questions about the role of nurses. One classmate told the story of her baby’s stillbirth decades earlier. She thanked me for the sensitive rendition, allowing her to share her story.

The instructor said, “You’ve got something here.”

Recuerdo (I Remember) by jparadisi

Recuerdo (I Remember) by jparadisi

Recuerdo appeared in the college’s continuing education catalog the following spring. I was pleased with the painting’s reception, but I realize it could as easily have had the opposite effect: bringing a classmate to tears. Nurses’ stories are proverbial double-edged swords. When wielded thoughtfully, they heal. Even so, they can easily cut someone else to the bone.

I am aware of the power of story when practicing oncology nursing. I was occasionally a patient at the infusion clinic where I now work. My coworkers view the story I bring from the experience favorably. That I can teach tying scarves into attractive head coverings for chemo-induced alopecia is a plus. However, through trial and error, I have gained judiciousness about telling patients I am a cancer survivor.

Here are some self-imposed rules I follow about story telling in the patient care setting:

  • Know your patient’s prognosis. It’s one thing to tell a newly diagnosed stage 1 breast cancer patient that you are a survivor, and that her hair will grow back. It’s something else entirely to say the same thing to a woman with metastatic disease. Tailor the story to the patient’s needs.
  • Talk about cancer treatment in universal terms. Some cancers do not have the same level of news exposure and financial support as breast cancer. Cancer patients should not feel they have a less “special” kind of cancer.
  • If you are not ready to answer questions about your experience, don’t bring it up. It’s natural for patients in similar circumstances to ask what treatment options you chose. If we’re talking about breast cancer, they may ask if you had a mastectomy. If so, one or two? They may ask about sexuality, too. You might be judged for your answers. You have to stay therapeutic anyway.
  • Allow patients to have their own experiences. Cancer treatment is not one size fits all. Do not assume that a patient shares your concerns. Exchanging information is often best done through asking questions rather than offering opinions. Let the patient direct the conversation.
  • Know when to let go. Being a cancer survivor does not make me the world’s best oncology nurse. The experience is simply a tool at my disposal. What’s best for most patients is a team of expert, compassionate caregivers bringing their unique experiences to the conversation.

Have you had a health condition that impacts your approach to nursing — or a coworker who has? What advice would you share?

Diet As Tolerated: This Week’s Post for TheONC

Diet As Tolerated watercolor by jparadisi 2012

In yesterday’s post A Social License III: Nursing Synchronicity I write about an impromptu discussion with a young woman in a department store while shopping for work pants. It’s  common phenomenon for strangers to reach out to nurses even when we are off duty. I pair this post like a fine wine with my post this week for TheONC.org,  titled, Diet As Tolerated, which describes another off duty encounter, this time at a cocktail party in a trendy restaurant.

Started in February 2012, with almost 7,000 Likes on Facebook, TheONC.org is an online social forum where oncology nurses and cancer care teams can leverage their collective knowledge, nurture professional growth and emotionally support each other in a secure environment, as registration is required.

Moderated by oncology nurses and key opinion leaders, TheONC (The Oncology Nursing Community) features discussions and commentary covering key issues ranging from symptom management and palliative care to managing ethnic and cultural diversity.

Other resources in the community include:

  • A Library of resources including patient education materials and presentations by community members
  • Clinic Close-Up, where members can view video-based interviews with experts from large group practices, private practices, and academia covering a variety of topics
  • News items relevant to clinical practice
  • An interactive Quiz feature where nurses can test their diagnostic knowledge on a regular basis
  • A Calendar of national and regional events and meetings specific for oncology nurses and cancer support team members

TheONC is like having a weekly national oncology conference conveniently online. A wide range of topics have already been discussed, including Stem Cell Transplant, pediatric oncology, survivorship, nursing while going through cancer treatment, and much more. Once you’ve registered, posts can be saved for future reference.

Follow TheONC on Twitter @The-ONC, and Like us on Facebook.

A Social License III: Nursing Synchronicity

“It all depends on how we look at things, and not on how they are themselves”

Carl Jung

I love the moments of synchronicity Jung calls “significant coincidence.” Like when I need a topic for my nursing blog, and find it in a non-nursing setting, like last Friday, while shopping for a pair of pants for work in a department store.

She was unlocking the dressing room door for me, when the sales clerk, a young woman maybe twenty years old, asked if she could find other articles of clothing for me to try on. I told her I was shopping for work pants. She retrieved several pairs for me to try, then asked what kind of work I do. I told her I am a nurse.

“What kind of nursing?” she asked.

“Oncology,” I answered.

“Do you give chemotherapy?”

“Yes, I do.”

Nursing is a social license, meaning the public perceives us on duty even when we are not. Nursing strikes a chord in people concerned about their loved ones.

“My mom was a nurse,” she said.

For a moment, I don’t know what to say. Does she mean her mother changed careers, or does she mean she’s dead? It’s one thing to ask about a stranger’s possibly dead mother in a hospital, altogether something else to begin such a conversation in the public setting of a busy department store.

She throws me a bone: “My mother had cancer, so she isn’t working, but she’s in complete remission. She’s done with chemotherapy. It was hard, because she doesn’t live in this city, and I was here, going to college. She didn’t want me to miss college because of her cancer. Her nurse friends were really nice, not fake nice, really nice. They did a lot for her.”

I told her I am also a cancer survivor, and that you can’t have better friends than other nurses when you are ill. I told her I’m sure her mother wouldn’t want her to shipwreck her own life because of her cancer. I told her it was good she continued her college education.

Was it merely coincidental this young woman’s mother is a nurse, and a cancer survivor like me? Or did the encounter hold a deeper meaning? I don’t know, but I left the department store with the warm feeling I get when I feel a connection to another human being.

Maybe synchronicity is never significantly coincidental. Maybe synchronicity is the simple human need to reach out to each other in a meaningful way, and especially to a nurse.

TheONC.org: Resources and More for Oncology Nurses

Untitled. by jparadisi 2012

By now, readers know I blog weekly for TheONC. This week I write about dual identities as nurse and artist/writer in Curbside Consultation. My colleagues, employer, and frequent patients know about my art and blogging activity. Sometimes worlds collide.

The Oncology Nurse Community (TheONC.org) is a new online social forum for oncology nurses and cancer care teams where they can leverage their collective knowledge, nurture professional growth and emotionally support each other in a secure environment, as registration is required.

Moderated by oncology nurses and key opinion leaders, TheONC features discussions and commentary covering key issues ranging from symptom management and palliative care to managing ethnic and cultural diversity.

Other resources in the community include:

  • A Library of resources including patient education materials and presentations by community members
  • Clinic Close-Up, where members can view video-based interviews with experts from large group practices, private practices, and academia covering a variety of topics
  • News items relevant to clinical practice
  • An interactive Quiz feature where nurses can test their diagnostic knowledge on a regular basis
  • A Calendar of national and regional events and meetings specific for oncology nurses and cancer support team members

TheONC is like having a weekly national oncology conference conveniently online. A wide range of topics have already been discussed, including Stem Cell Transplant, pediatric oncology, survivorship, nursing while going through cancer treatment, and much more. Once you’ve registered, posts can be saved for future reference.

Follow TheONC on Twitter @The-ONC, and Like us on Facebook.

A Get Well Card for Warren Buffet

photo: jparadisi

As an oncology nurse, if I listened to the family members of an affluent, elderly patient debating at his bedside his right to receive cancer treatment, insisting he is too old, I would suspect elder abuse, and call for a social service consultation. Yet, this very scenario is occurring throughout the media in response to Warren E. Buffet’s announcement last week that he has stage I prostate cancer and will undergo eight weeks of daily radiation treatment, beginning in July.

The hullabaloo is in regards to guidelines established by the U.S. Preventive Services Task Force (USPSTF) recommending that men over age 75 not receive prostate cancer screening, aka the simple PSA blood test. 81 year-old Buffet not only received the PSA test, but when the results came back raised, he under went a prostate biopsy, which is also a no-no for a man his age per USPSTF guidelines. This is how his prostate cancer was diagnosed.  USPSTF recommendations for treating slow-growing stage I prostate cancer consist of a digital rectal exam (DRE), and PSA test every 3-6 months, with annual prostate biopsy (see link above). Mr. Buffet’s choices for cancer treatment drives at least one oncology urologist batshit. By the way, the USPSTF is the same task force that presented new mammogram guidelines in 2009, sending women’s health groups to arms.

I’m no expert on prostate cancer, hell; I don’t even have a prostate. But if I did, I would consider it my right to choose how to treat it if it were diseased, assuming I am presented with appropriate choices. There are a few things I do know: Warren Buffet is one of the good guys. An outspoken advocate of fair play, he proposed The Buffet Rule a $47 billion tax increase on the nation’s richest households, which the House voted down earlier this month. He is also one of 81 billionaires pledging to give away more than half their personal wealth to philanthropy when they die.

Do I believe Warren Buffet deserves special health care privileges because he is powerful, wealthy, and generous? No. I believe everyone has the right to their informed health care choices, and have those choices respected by their providers, families, and friends, without scrutiny. A cancer diagnosis and treatment is difficult enough without this added burden, whether the patient is unemployed, homeless, or the third richest man in the world.

A man with the power and affluence of Mr. Buffet is most likely unconcerned about the opinions of the media, and even less with mine. But for what it’s worth, Mr. Buffet, from an oncology nurse in Portland, Oregon, I wish you the best throughout your cancer treatment, and send positive thoughts for a speedy recovery.

TheONC: A New Blogging Community for Oncology Nurses and Teams

Last week CancerNetwork launched TheONC; an online community for oncology nurses and staff. TheONC is a gated site for professionals so login is required to participate. The video link below explains more fully:

video.asp?section_id=1687&doc_id=238579

TheONC features bloggers with a wide spectrum of expertise writing on various aspects of cancer care. As a contributing blogger, I write from the perspective of an artist working in oncology. Through weekly posts, readers and I will discuss creativity, and its pursuit, in nursing. Images of my artwork accompany the posts. My first went live yesterday.