Toilet Texting? Keep Your Cell Phone to Yourself!

Bug on a Cell Phone photo: jparadisi 2011

As much as I love patient care, I do have a pet peeve. It goes like this:

Occasionally, a patient arrives expecting something to happen during their appointment that wasn’t ordered by the doctor. Within reason, I am happy to call the doctor’s office on their behalf and request the lab test, simple injection, or whatever. For a very few patients, however, this isn’t enough. They whip out their cell phone and call the doctor themselves. I don’t terribly mind patients using their cell phones in the clinic, but I hate it when a patient hands me their cell phone and expects me to talk to their doctor. I have always imagined entire cities of respiratory germs prospering on the surface of a cell phone. I don’t want to put their cell phone up to my ear and near my face. Blech!

Turns out, it’s worse than I imagined. Medscape published an article by Tim Locke, exposing the results of a UK study of bacteria found on cell phones:

“The next time you reach for your cell phone, consider this: A new study found that 92% of cell phones in the U.K. have bacteria on them – including E. coli — because people aren’t washing their hands after going to the bathroom.”

Who texts on the toilet? Uggh!

And please, everybody wash your hands!

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.


10 Things to Do On Time-Limited Medical Leave

Three Horses oil & graphite on canvas by jparadisi

I expected to return to work today, but a temporary administrative glitch changed those plans. Rather than languish at home, I’ll write about things to do while on a time-limited medical leave, derived from my own experience.

  1. Finally read Middlemarch, by George Eliot. Okay, I haven’t actually read it yet, but I downloaded the free version to my Kindle this morning. Free is a very good price on disability wages.
  2. Make new friends on Facebook, also free.
  3. Ask my daughter, the hairstylist to give me a cute new haircut. She gave this service as a gift.
  4. Call my mother more often and realize how much I enjoy our leisurely conversations.
  5. Spend time with my favorite eleven year-old. Unfortunately, his toddler sister weighs more than I’m currently allowed to lift. Sigh.
  6. Learn how to apply make up like a pro. By way of charming and entertaining videos, Marlena at Makeup Geek teaches how to create a smoky eye, and wear red lipstick without it making you look clownish. She explains which brushes you need and how to use them. She offers alternative products to more the expensive department store brands. This is a fun site to watch with your teenage daughter if either of you want to bump up your everyday look once in a while.
  7. Walk alternative routes in the neighborhood and see what’s new.
  8. Earn continuing education units. In order to maintain my OCN certification, I’m required to complete 100 units of CE every four years. CE is expensive at $10-$20 per unit. Medscape offers CE in 0.5-2 unit increments free and provides a convenient on-line CE tracker.
  9. Thoughtfully consider my direction as an artist and writer, and plan new goals.
  10. Send a platter of cookies to my colleagues at work, because I’m sorry I’m not there to pick up my part.

No Winning for Losing

Manga (we've made all your favorite foods) photo: jparadisi

Every year, the day after Halloween marks Opening Day of Seasonal Gift-Eating. Nurses, you know what I’m talking about. All over America, nurse lounges abound with gifts of food given to us by patients and doctors offices. Huge canisters of gourmet popcorn, boxes of chocolate, and homemade delicacies arrive and cover all available counter space. Even if there’s no time for a lunch break, there’s always a few seconds to grab a piece of fudge. So it’s a little unfair, in my opinion, that health care is focusing on the issue of obesity, even though I know it’s right.

Many patients, female in particular, cringe when I ask them to step on the scale at their appointments.  I don’t say their weight out loud, but simply enter it into their chart. In the December issue of the American Journal of Nursing, Carol Potera reports on the emotional impact on patients of words used to describe their weight in Words Can Hurt. The information comes from a study led by clinical psychologist Gareth Dutton. I found the study’s contrast of words used by physicians versus words used by nurses to describe patient weight enlightening.

Medscape published an article Is “Fat Bias” Making You Ineffective? by Marilyn W. Edmunds PhD, CRNP, in which she calls upon health care providers to reflect upon our biases and how they impact our patients. She also asks us to consider cultural differences in perception of weight.

We’re not the only ones looking and judging, however. Recently at an art opening, another artist told me I am the only nurse he’s ever met who isn’t overweight, and it wasn’t the first time someone has said this to me. I find this public stereotype of nurses more troubling than Dr. Oz’s sexy nurses, who were really women who lost weight, although I agree the entire debacle was in poor taste.

I want to throw one more point into this post. A patient came in raging about fast food chains. I didn’t really get it until he explained that fast food is cheap, so for people living on the limited resources of disability, it is affordable. All the fat, all the sodium, the lack of nutrients from over-processing, is all he can afford. And then he comes in for his appointment and gets lectured on his A1C Hgb results, hypertension, and obesity. In his opinion, there’s no winning for losing.

Who’s a Jethro? Thoughts on an Aging Nurse Population

Study Detail/artist: JParadisi (2009)

     My patient was watching The Beverly Hillbillies on TV while I set up the supplies needed to start her IV. I stopped what I was doing when she said, “What is this show? Is it a movie? What’s the name of this show?”  

     “How young are you?”, I asked, gesturing towards the TV.  “That’s The Beverly Hillbillies. You know how people say, What a Jethro? Well, that’s Jethro. He’s always coming up with good ideas that don’t actually work.”  

     I’m not all that old myself. The Beverly Hillbillies was already in syndicated reruns when I was in elementary school. However, I meet the over 40 criteria which the Age Discrimination and Employment Act uses to identify “older” employees.  

      I read an article on Medscape,  Retaining an Aging Nurse Workforce: Perception of Human Resources Practices, written by Mary Val Palumbo, Barbara McIntosh, Betty Rambur, and Shelly Naud. The paper explains that a majority of employed nurses are over 45, and Human Resources departments worldwide are looking for ways to increase retention of nurses into their 60’s.  

     According to studies, nurses want three things from the organizations they work for:  

  • Recognition and Respect
  • Having a Voice
  • Receiving Feedback

     Really? That’s what nurses in studies say they want? Really?  

      Listening to my colleagues discuss what they want, increased healthcare benefits, increased reimbursement for educational conferences, pay increases for career related achievements such as advanced degrees and certifications, are examples of what nurses want. I think this falls under Recognition.   

     Nurses universally complain about missing scheduled breaks because of too heavy patient assignments, and uninterrupted lunch breaks are considered a luxury by most of us.  Some department managers even post important notices such as changes in policy on the staff bathroom walls, to read during our “bathroom breaks”. Fortunately, the walls of the staff bathroom where I work are free of required reading. This probably falls under the Respect category.  

     Coincidentally, I attended a Human Resources customer service presentation. A Power Point slide projected a scripted phrase to ask the patient (customer): Is there is anything else I can do for you? I have the time.”  The HR representative emphasized that studies show the phrase “I have the time” is a crucial part of the customer service interaction, and we were urged to say it.  I raised my hand: “I’m playing devil’s advocate here: if the phrase is of such importance, then shouldn’t staff be provided with the necessary resources ( i.e. time = staffing)  to say it truthfully?”  

  • Recognition and Respect
  • Having a Voice
  • Receiving Feedback

will never be achieved unless nurses of all ages find the voice to clearly define what these terms mean to us.