Shifting Closer to “Where Science, Humanity and Art Converge”

A goal is a dream with a deadline.

-multiple Internet attributions.

 

I have a new job, one that I envisioned when I transitioned from pediatrics to oncology nursing in 2001.

I am an oncology nurse navigator.

If you don’t know what an oncology nurse navigator is you’re not alone. Most of the time when I tell another nurse about my new job, his or her eyes go blank, and I get a sincere, but confused, “Oh congratulations!” Surprisingly, or maybe not, it’s my layman friends who get it right away, “It’s about time the medical profession started hiring people to help us find our way through the complexity of health care.”

I can’t agree more.

Patients are referred to a navigator after a diagnosis of cancer. The role involves patient education, distress assessment, providing resources, and emotional support throughout treatment. The goal is patient-centered care that prevents patients from “falling through the cracks” of the health care system. Confusion arises because some duties of the nurse navigator resemble those of case managers and social workers, however, nurse navigators offer comprehensive oversight of patient care needs, and advocacy. Further, the American College of Surgeons’ Commission on Cancer mandates patient navigation for cancer program accreditation. A source of more information is the American Academy of Oncology Nurse Navigators’ website.

One of many adjustments is my work hours have increased from nearly full-time to full-time. But there’s so much to write about! As I get a handle on things, I suspect the focus of JParadisiRN blog will shift closer than ever to “where science, humanity, and art converge.”

 

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?

A Member of the New Uninsured Apologizes to President Obama

I Wish I Could Have Sold More Cookies to Pay For My Surgery photo: jparadisi 2011

In previous posts, I propound Universal Access to health care. I’m not particularly attached to whether states individually create their models, or if it is federally operated. I believe no one should go without health care.

As I’ve written before on this blog, the faces of the uninsured are changing. Yesterday, the Los Angeles Times featured an Op-Ed, Breast Cancer, Health Care, and a Public Apology to President Obama, by Spike Dolomite Ward, who typifies the New Uninsured. Her plight describes that of many of the patients admitted to the outpatient oncology infusion clinic where I work.

Many people tell me, “I take good care of my health. That’s my health care insurance.” Ward’s essay illustrates how that sort of believism isn’t enough.

Elementary My Dear Watson, Ambulatory Care Is a Specialty

I almost shouted, “No Sh*#t Sherlock,” at Medscape when I saw the article Ambulatory Care Nursing: Yes, It’s a Specialty, by Laura A. Stokowski, RN, MS. Once I got past the title and read the article, however, I found Stokowski’s grasp of ambulatory care nursing accurate.

When I left Pediatric Intensive Care to work in a hospital based oncology/ infusion clinic, I had to acquire oncology skills and national certification (OCN). I also had to revise my approach to patient care.  Ambulatory care is different from inpatient nursing, but no less challenging. Each requires a large amount of knowledge, expert assessment skills coupled with critical thinking, and the ability to communicate clearly and accurately to a variety of educational levels. Unlike inpatient nursing, outpatient continuity of care necessitates coordination with home infusion, hospice, pharmacies, and other medical offices. Often these services occur outside of the hospital system of our clinic, and information exchange creates extra work. An understanding of insurance carriers, ICD codes, pre-authorization, and billing is helpful. I never worried about this part of healthcare when I worked in a hospital.

Our clinic is nurse run. We are not Nurse Practioners. Most days, my only contact with a physician occurs through his or her medical assistant over the telephone. Physicians send their patients with orders for treatments. We schedule the patients; they get their treatments, and go home, most of the time. Occasionally, patients confuse ambulatory care with emergency care, and they come in too sick for our services. We deliver them to the ER for triage instead. Part of my job is making sure they are in the right department for the care they need.

As a PICU nurse, I was used to taking report from an ER nurse, not giving report to one. Occasionally, I’d catch a nurse rolling his or her eyes at me, indicating doubt that the patient needed a hospital admission. After a time or two I’ve proven I know a sick patient when I see one.

We infuse blood products, and medications requiring close monitoring such as chemotherapies, Rituxan, Remicade, IVIG, and first-time doses of IV or IM antibiotics. Most reactions patients experience are controlled by slowing the infusion rate and additional pre medications, but it is not unusual to hear a shout from a nurse and find a patient in the beginning phase of anaphylaxis. I have acquired ninja-like skill with subcutaneous Epi-pens.

We have advanced IV and Central Venous Access Device (CVAD) skills, because we are responsible for the care of our patients’ PICC and midlines, ports, Broviacs, and with permission from their doctors, dialysis catheters. If any of these devices clot, they come to us for first-line treatment.

We do a LOT of teaching about cancer care, including stem cell transplant mobilization and tri-lumen catheter care. Encompassed in teaching oncology patients is compassionate presence, the ability to sit quietly listening to the patient and their caregivers. In my opinion, this is the most rewarding part of our work, and the juncture where science, humanity, and art converge.

Stokowski reveals the long-term relationships ambulatory care nurses develop with patients over years of care. Professional boundaries with patients seen multiple times a week over years poses a different set of challenges for the ambulatory care nurse versus an inpatient nurse. I imagine it’s even more challenging for hospice and home care nurses.

On weekends, patients often ask if I like my job. What they want to know is if I mind giving up my Saturday, Sunday, or holiday caring for them. Nursing sort of makes one day equal to another; weekends aren’t special to me. I explain that what I enjoy most about ambulatory nursing is that, at the end of the day, everyone gets to go home. When I worked inpatient, it felt like a continuing onslaught of never ending tasks; only the person in the bed changed. It felt like a relay race: the baton is passed from runner to runner, but somehow the finish line is never in sight. Ambulatory care is more like a 10K: You go as fast as you can, as hard as you can, but at the end of the day, you’ve finished the race. Everyone has a night to himself or herself. The sun rises again, and we come back and start over, anticipating the challenges of a new day.

 

A Response to The Torture Memos

     Many people have their lives saved daily by surgeons who have learned the discipline of doing the unthinkable in order to accomplish the miraculous.

     Ask a trauma patient, transplant patient, or the parents of a child undergoing open heart surgery.

     Anesthesia and sterile drapes covering the usually unconscious patient certainly aids the surgeon in her duties. Health care providers go to work each day to help, not torture.

     Perhaps the answer to the paradox is in the body of the essay(The Surgeon and the Torture Memos, NY Times, by Dr. Pauline Chen http://www.nytimes.com/2009/04/30/health/30chen.html): Dr. Chen describes the torturers as “seemingly ordinary professionals”…”not just a rogue group of military grunts.” It is difficult for Dr. Chen to imagine someone like herself committing tortuous acts, but not a “military grunt” (also a human being), which I interpret to mean a person who is not educated in a profession. Does less education equate to less humanity?

     In my opinion, when we begin to differentiate humans into categories of “us/me” and “them/you”, we begin the processes of desensitization and habituation. This differentiation between categories of people allows us to find the justification to harm others, because “they are not like us.”

     Sometimes, people commit acts so horrific that it appears they have chosen to no longer abide within the constraints of civilized society, and justice needs to be rendered. For that purpose, we have a legal system.

Health Insurance Advice for the Newly Unemployed

     There is an informative article in today’s NY Times by Lesley Alderman that lists resources for families and individuals who are recently unemployed. If you are in this situation I strongly encourage you to read the article.  Many of the resources are direct results of the newly passed Stimulus Package. Here’s the link:

Advice to the Jobless on Getting Health Care Coverage

by Lesley Alderman  for the NY Times

http://www.nytimes.com/2009/02/28/health/policy/28patient.html?partner=rss&emc=rss

Follow Up : A Personal Response to Moral Distress in Health Care

 

detail from Goldsmith Artists collaborative project 2008

detail from Goldsmith Artists collaborative project 2008

 

In  my post

A Personal Response to Moral Distress in Health Care (Feb. 7, 2009), I describe events leading to an uninsured, homeless man’s admission to an emergency department.

From there he was admitted into the hospital.

I was off for a couple of days after that event. When I came back to work, I was told that the man called our clinic from his hospital bed “just to check in” and to thank us, “his nurses.”

He will discharge soon, and I will see him again in the clinic. There are no indications that his lifestyle has changed. No miracle has occurred.

But I can’t keep from smiling about his phone call to us and my awareness that a simple human connection was made that day. It makes me feel hopeful. It helps me continue advocating for the voiceless.

I am reminded of an adage I heard some where:

If you want to change the way you feel about someone, change the way you treat them.

 

A Personal Response to Moral Distress in Health Care

oil on wood 2008 J.Paradisi

oil on wood 2008 J.Paradisi

This morning I visited Pauline Chen MD’s Well blog at the NY Times on-line to read comments posted to her Moral Distress article. There were many, mostly from MDs, a few by nurses, and one from a patient, who’s life was saved when an ICU nurse challenged the doctors treating him.  The strong emotions reveal the virulence of the topic.

The article resonated for me. I read it after returning home from a particularly busy shift. In the clinic, I saw a patient and knew something had changed since our last encounter. The tension of his muscles indicated pain, but he didn’t ask for medication for it. He knew better. Let’s just say that his track record of lifestyle choices make him a less than stellar patient. The package of cigarettes in his shirt pocket is his least dangerous vice and negates the purpose of the medication his doctor prescribes for his asthma. Still, something was clearly wrong with the man, and my job is to be his advocate, not his judge.

So, I looked closer, to see if I could spot the problem causing the change. I found it: his calves were swollen to twice their normal size above his ankles; his soiled socks acted as  compression wraps, so his ankles were deceptively normal. Taking a stethoscope to his chest, I heard the anticipated expiratory wheezes, but otherwise muffled breath sounds. CHF, congestive heart failure. We were treating him for another condition, unrelated to his heart, but CHF added itself to his problem list anyway. He needed treatment.

I paged the doctor who ordered his care. The doctor called me back from the  ICU, where he was treating a seriously ill patient, hopefully a compliant one. He patiently explained to me he was no longer treating my patient. He had only been brought in as a consult to begin with, and my patient was not following instructions, and missed appointments. He had sick patients who were trying to get well needing his care. He doesn’t have the time or resources to continue treating a patient who thwarts all efforts to improve his condition. I heard what he was saying, and I understood.

Choices have to be made. Still, I was the one looking at a human being and watching him struggle to breathe.  I called another health care provider familiar with this patient, and he was sympathetic, but my patient wasn’t under his care either. I would guess this provider has fifty to one hundred patients just like this one whom he is committed to caring for; I cannot accuse him of a lack of compassion.

The patient in front of me was now wheezing audibly. Never particularly conversant,  now he  only responded to my questions in monosyllables.

I had to make a decision. I seated him in a wheel chair, and walked him to the emergency department. It was a particularly busy day there, but the triage RN was very kind, and efficient. We both knew this noncompliant, substance abusing, uninsured, suffering, frightened patient was very ill and would be admitted to an expensive, and hard to come by hospital bed. But what was our choice? In the face of economic crisis, outpatient resources are cut by the minute, leaving emergency departments and inpatient care the only avenues available for the uninsured.

And lately,the faces of the uninsured are morphing in front of me. They aren’t always dressed in dirty socks and flannel shirts. Now I see unfunded patients with expensive college degrees who used to have jobs, and they are parents of a child or two, as lay- offs create a new kind of uninsured patient.  Will I be asked to choose which kind of unfunded patient gets care, as hospital funding dries up, and administrators have to decide where to make more cuts in order to keep the hospital solvent?  This is the moral monster underneath the bed I fear, and even with the lights turned on,  it’s not my imagination.