Nursing The Unexpected Job Change

Besides reimbursement changes, The Affordable Care Act (ACA) calls for the formation of Accountable Care Organizations (ACOs): joint ventures coordinated by hospitals and providers in communities in which they stop competing and create coordinated services for patients, thereby reducing the cost of care.

I said NEO, not Nemo by jparadisi

I said NEO, not Nemo by jparadisi

In this vein, the hospital I worked for has undertaken collaboration with another hospital to provide outpatient oncology care for patients. As a result, after working for the same healthcare system for nearly 20 years, I have become an employee of the other hospital. Though my job is basically the same, I unexpectedly find myself working for a new healthcare system.

In many ways this change is actually beneficial. However, it has also created turmoil for my coworkers and me.

For instance, there is the expectation that we occasionally float to locations other than our home unit, involving commutes for some. Vacation plans beyond the new hire date are uncertain; we’ve been asked not to request vacations until after the end of the year (2013). New benefits packages require reading, new retirement options must be considered, and there is a different pay scale than what we were accustomed to. I want to reiterate, none of this is a bad thing, but when a job change is unexpected it creates disruption. Here are some coping skills I learned, in case it happens to you:

  • Get your vacation plans approved by your manager as soon as you are aware of the job change. Merging two staffs means some people won’t get the time slots they desire.
  • Polish your resumé. Find the addresses of the schools you attended, remember the names of past managers, and assemble reference contacts. Even if you are automatically offered a job with the new employer, you will have to fill out a job application.
  • Anticipate drug testing as part of the hiring process. This was my first time ever!
  • Make dental, vision, and medical appointments, and renew your prescriptions before the new hire date, in case your new insurance coverage makes it necessary to seek new providers.
  • If you can’t rollover your sick leave or vacation time, consider using as much of it as you can before the job change. It might be taxed at a lower rate that way.
  • Remain calm, and avoid the rumor mill. Find out who is authorized to answer your questions, and get as many answers in writing as possible.
  • Be patient. ACOs are new for everyone. Administrators and human resources personnel are also learning facts as the project develops. They are not necessarily purposely vague. They really may not know the answers to your questions yet.

Finally, remember this: Regardless of the changes, patient care and safety are pretty much the same everywhere. Your employer may change, but you still know how to be a nurse.

A Blue Mason Jar Full of Post-It Notes Goals for The New Year

Note from JParadisiRN: This post was originally published on this blog in 2011. As it remains one of my most popular, I dusted it off for you to read today. Happy New Year 2014!

Every year I write my New Year’s resolutions on Post-It notes, filling a blue, vintageMason jar with them after reviewing the ones from the year before. I write the date on each Post-It note.  If a previous year’s resolution wasn’t met, and still holds merit, it remains in the Mason jar with the new ones.

Blue Mason Jar of Dreams photo: jparadisi 2011

Blue Mason Jar of Dreams photo: jparadisi 2011

Previous years’ resolutions in the jar:

  • “My health: that I may remain cancer-free” (1999)
  • “The continued good health of our families” (1999) I updated this one to “our families” in 2004, the year David and I married.
  • “David’s and my continued good health and happy marriage” (2008)
  • “To show a financial profit as an artist.” (2008)
  • “Gallery representation”(2008)
  • “Publish more stories in 2011” (2010)
  • “A book deal for my manuscript” (2010)
  • “The blog will have more than 1,000 visitors/month (2010)
  • “Lose ten pounds” (2011)

Most striking about the hopes and dreams on this list is that none of them are actually resolvable. They are ongoing. Sure, publishing The Adventures of Nurse Niki into a book, (or better yet, a TV series) would be great, however, knowing me, the next year I would resolve to write another book, one that won an award or topped the charts, or something like that. Artists are rarely satisfied with any level of achievement. We are always looking up the ladder at the next rung:

  • Gallery representation leads to the desire for critical recognition, increased sales, collectors, fame.
  • Publishing stories leads to writing more stories, longer ones, for larger audiences.

In general, human nature is much the same:

  • Health and happiness leads to the expectation for more of the same.
  • I lost ten pounds last year. For 2012 I expect to keep them off.

Resolution is the wrong choice of word. For me, setting New Year’s Goals is better phraseology. Most of the improvements I wish for in life take time and perseverance to achieve, and more hard work to maintain. To my way of thinking, New Year’s is a time to review the larger goals of my life, and see if they are still worth steering towards. If so, then I ask myself what small adjustments can I make this year to further them? These adjustments are written as goals on the Post-It notes, dated, and placed in the jar.

The most important part of opening the Mason jar each year is reading the hand written Post-It notes, and saying a small prayer of thanks or another expression of gratitude for the advances, which occurred over the past year towards each goal. There is no lasting joy in achievement without gratitude. This year, I am thankful for:

  • A clean bill of health when we were afraid my cancer had returned.
  • Editors who published my paintingsessays, and blog posts.
  • David and I lost weight. He avoided a prescription for blood pressure medication.
  • I was represented by Anka Gallery. I met wonderful people there and made lasting friendships.
  • I sold some paintings.
  • JParadisi RN blog has grown beyond my previous goals.

So what’s on Post-It notes this year? What goals am I steering my life towards in 2012?

  •  Remain cancer free
  • The continued good health of our families
  • David’s and my continued good health and happy marriage
  •  A financial profit as an artist
  • Finish the series of paintings and drawings begun in 2013
  • Gallery representation
  • Write and publish more stories in 2014
  • Increased writing income
  • The blogs, especially The Adventures of Nurse Niki will grow increased readership
  • Keep off those ten pounds

Here’s the cool thing about writing down goals: The Examined Life (Socrates). Today I see  each goal I’ve written down is focused on an unknown future. I haven’t written a single one, which applies to my present reality. So, until my dreams come true:

  • I will continue to develop my skills as a nurse so my patients remain safe in my care.
  • I will strive to be a better team player at work.
  • I will phrase criticism in a constructive manner.
  • I will remember that everyone has a difficult job. That’s why they call it work.
  • I will say Thank You at least once daily. It’s wrong to wait an entire year to give thanks for everything that is good in my life.

I wish to thank my family and friends (new and old) for your support of JParadisi RN blog. May your New Year be filled with Health, Love, Happiness, and Prosperity.

Nurses and Holiday Stress

Painting by jparadisi

Painting by jparadisi

Nursing potentiates normal holiday stressors. For many nurses, the beauty of the winter holidays is diminished by feelings of stress.

Staffing woes contribute: Who knows why every year during the holidays, patient census randomly explodes abundantly or trickles down to near nothing, resulting in too much overtime or hours-deficient paychecks?

We go home to enjoy the glow of Christmas tree lights knowing our patients spend their holidays in a hospital or hospice bed, their rooms lit by overhead fluorescent lights, and this knowledge dampens a nurse’s ability to fully enjoy celebrations of bounty. We may experience feelings of guilt that our income is dependent on the misfortune of others, in this case, illness or trauma.

Mismatched schedules, especially those of night-shift nurses, complicate holiday arrangements with family. Gift giving weighs heavily on sensitive souls: Instead of buying gifts, shouldn’t the money be given to those in need? Or are our expressions of love for family and friends, the creation of memories and traditions left after our own health fails, equally important? Someday, we will become the ones missing from the family dinner table of Christmas’s future.

Here are suggestions for handling holiday stress:

  • Reduce expectations. Holiday preparations and gifts are expressions of love, not declarations of wealth. Stay within your physical and fiscal boundaries.
  • Plan quick, easy, and low-calorie meals in between holiday parties. You’ll feel better.
  • Enlist the help of children with holiday baking and food preparation. This is an opportunity to teach them to cook while spending time together.
  • Lighten your housework load by asking children to help with age-appropriate tasks like dusting, folding clothes, drying dishes, etc. Work out a payment incentive with them. Encourage them to use the money for Christmas shopping, to buy a toy for a less fortunate child, or donate to a food bank.
  • Plan downtime and use it for activities with personal meaning. Don’t skip yoga class or your morning run. Take a break from wrapping gifts for a cup of fragrant hot tea or cocoa with marshmallows. Spend an hour at church, take a long walk, or meditate to regain your sense of grounding.
  • Remember the gifts you give. Nurses give to their patients throughout the year gifts that cannot be remunerated on a paycheck. Although we do not have magic wands to cure disease, taking time to listen and help patients with their needs goes a long way. The best way to feel better is to help someone else feel better. This is the gift of nursing.

Does your nursing job ever affect your ability to enjoy the holidays? What steps do you take to reduce holiday stress?

For The Nurse on Your Holiday List: A “Shift From Hell” Emergency Kit

As if the onslaught of commercials isn’t enough to remind us, the winter holiday season has begun. For nurses, whose patients always seem to worsen, or expire, around the holidays, jumbled feelings of anxiety and guilt may arise.

‘Tis the season to practice extra strength self-care and creative gift giving!

If you need an idea for an inexpensive holiday gift for a preceptor, mentor, student, or that special nurse buddy who always has your back, here’s an idea: Give him or her a Shift From Hell emergency kit for their locker or fanny pack. The contents will vary with your own creative ideas, but here are some suggestions gleaned from my 25 + years of bedside nursing:

  • Nail clippers: for fixing a broken or snagged nail
  • An emery board: see above
  • A pair of tweezers — for wayward eyebrow or nasal hairs
  • A package of toothpicks: Does anyone share my irrational fear of food stuck in my teeth?
  • A small package of antacids: They can mean the difference between leaving a shift early or staying to finish it
  • A travel-size package of ibuprofen or acetaminophen for unexpected headaches and minor pain
  • A laundry detergent pen or wipes to remove betadine, coffee, or blood stains from scrubs and lab coats before they set.
  • Lip balm — For those shifts when you don’t have time to drink enough fluids
  • Change for the vending machine — particularly useful on the night shift
  • Gum or breath mints
  • A hair tie as back-up for the one you wore to work that broke
  • A cheap pair of reading glasses: because who can read that tiny print on single dose medication vials?
  • Packages of fancy instant coffee, a fragrant tea, or cocoa — for when you finally get a moment to sit down
  • Chocolate

Remember to keep the supplies miniature. Collect them into a cloth drawstring bag, coffee mug, or Mason jar. Those cosmetic bags you get as a “gift with purchase” from department stores work, too. Add a bow and gift tag: voilà!

If you prefer a gift for your unit while maintaining a budget, consider buying larger amounts of the supplies, and place them in a basket lined with tissue paper or gift straw, as a group gift available in the staff lounge.

What items do you consider essential items for a nurse’s Shift From Hell?

Vascular Air Embolism: Explaining Tiny Bubbles to Patients

It happens almost every shift — I hang an IV infusion, and no matter how carefully the tubing is primed, at least one tiny bubble passes the pump’s electronic air detector, and floats its way towards my patient. The patient reacts with a tense expression, visually following the tiny bubble’s journey to the IV site. “Is it okay to have an air bubble in the tubing?”

Tiny Bubbles by jparadisi

Tiny Bubbles by jparadisi

I know they are thinking of the TV medical dramas of the 70s and 80s, shows like Mannix, or Quincy, in which a murderer sneaks into a hospital room and carefully injects the tiniest of bubbles into the IV tubing of the sleeping victim, who suddenly codes while the murderer, dressed in scrubs, slinks away unnoticed.

The question remains, however: How much air is too much in venous access? The answer is — the amount that makes a patient symptomatic.

Minor cases of air embolism are common and cause minimal or no symptoms. Severe cases are characterized by hemodynamic collapse and/or acute insufficiency of certain organs, including the lungs, brain, and spinal cord.¹

This is not new information for experienced nurses, but it is for most patients. Nearly all VAE (venous air embolism) occurs in conjunction with venous access devices. In fact,

60-90 percent are caused by “fractures or detachment of catheter connections.”¹

Other factors include:

  • Failure to occlude the needle hub and catheter while inserting or discontinuing an IV site
  • Self-sealing valve failure
  • A tract that remains after central venous catheter removal
  • Positioning the patient upright during central venous catheter removal

Oncology nurses use venous access devices regularly. VAE prevention includes:

  • Priming IV infusion tubing and needle hubs
  • Testing nurse inserted catheters for patency before insertion
  • Securing all IV and central line connectors
  • Instructing patients to perform a Valsalva Maneuver during central line removal
  • Placing patients in supine position during central venous catheter removal
  • Covering the removal sites of central venous catheters with an occlusive dressing

Symptoms of air embolism include:

  • Dyspnea
  • Chest pain
  • Sense of impending doom
  • Lightheadedness
  • Tachypnea
  • Tachycardia
  • Hypotension
  • Wheezing
  • Change in mental status

Severe air embolism is a medical emergency. If you suspect air embolus:

  • Call the Rapid Response Team or Code Team
  • Place the patient in left decubitus position
  • Begin supplemental O2

Prevention is the best treatment for an air embolus. All oncology nurses should demonstrate infusion therapy competency in the patient care setting.

Have you witnessed a patient experiencing VAE? What recommendations for preventing VAE would you add? What policies have your workplace initiated?

References:

  1. Air Embolism, 2013 UpToDate Authors: Liza C O’Dowd, MD, Mark A Kelley, MD, Section Editor: Jess Mandel, MD, Deputy Geraldine Finlay, MD

Hand

 “All nurses are different. Some just jab the needle into you, and it hurts.”

-A patient

White Gloves by jparadisi

White Gloves by jparadisi

Few things make me feel more successful as a nurse than when a patient says, “That was the most painless port access, (IV start, or injection) I’ve ever had.” I can never promise a patient I won’t hurt them, but when I don’t, it makes my day. I strive for a gentle hand. 

In art the term “hand” describes the workmanship of an artist, and nurses often tell patients going to surgery, “You’re in good hands,” referring to a surgeon’s skill with a scalpel. But “hand” refers to the way we treat people too.

Whether educating patients about chemotherapy and radiation regimens, explaining home medication administration, or simply discussing current events, it’s important to remember that even the most optimistic patient is emotionally fragile. Tone of voice, the abruptness of an encounter, and our choice of words all contribute to the “hand” we touch them with emotionally. Too heavy of a conversational hand can pierce a patient’s soul as painfully as any needle or scalpel.

I forgot this during a shift memorable for both the number and acuity of its patients. Everyone had complex questions about their care. I enjoy patient education; however, this shift I was doing so much that I began pulling information from my knowledge base as if it were files from a computer. By this, I mean remotely. I wasn’t paying attention to hand, my personal touch.

During the course of an assessment, a patient revealed she wasn’t taking a prescribed home medication because of its side effects. The patient also reported a symptom, which I recognized was caused by the discontinuation of the home medication she’d just mentioned, and I just sort of blurted out my observation. Immediately, I regretted my heavy-handedness as I saw this otherwise optimistic patient crumble nearly to the point of tears. I had carelessly broken a tender reed.

Needing to make amends, I sat on the rolly stool, and I apologized. I complimented her involvement in her care, and her ability to sense changes in her body. I also apologized for abruptly responding to the discontinuation of her medication. I regained my gently touch, she forgave me, and we devised with a care plan.

I hope I made up careless hand. I had hurt her as if I’d jabbed her with a needle.

How to Give Good Phone

by jparadisi

painting by jparadisi 2013

Nurses spend lots of time on the telephone. So much, that I believe How to Give Good Phone should be taught in nursing school as a subtopic of therapeutic communication. For the rest of us, here’s a crash course developed over the years.

We all remember that communication has three components: sender, receiver, and a message:

Sender. Nurses call other departments for a variety of reasons. We call material supplies requesting special bio-occlusive dressings for patients with adhesive allergies. We call the pharmacist with questions about unfamiliar medications. We call physicians requesting new orders when a patient isn’t doing so well.

Receiver. Nurses also receive phone calls. Physicians call to admit patients. The lab calls, announcing we didn’t send the blood tests in the right colored tubes, and they need to be redrawn.

Someone we don’t know calls, asking if his mother, who we also don’t know because she is not one of our patients, is done with her appointment. When we ask him for more information to find her, the caller misconstrued this to mean we’ve misplaced his mother, which brings me to…

Message. Clarity begins with the sender. Intuitively, message should be the simplest part of the communication process, but in fact it is often the most difficult, especially over the phone, where visual information is lost to the sender, the receiver, or both. This loss of visual information is what makes reading back a telephone order by a nurse to a physician a critical component of that type of communication.

Here’s another example: you’re calling in a hemoglobin value to the physician. If the lab value indicates borderline for anemia, but you strongly feel the patient would benefit from a transfusion, you would want to include the subjective symptoms you see at the patient’s bedside: headache, shortness of breath on exertion, and increased fatigue. Knowing that you are going to suggest a transfusion for this patient based his clinical assessment before pushing the phone number keeps the message on track and focused on the patient.

I’ve been the sender of a message to a receiver (not a physician), who appeared confused about our roles. She did all the talking.  This obstructed my message. Perhaps anxiety caused her to blurt out lengthy commentary irrelevant to the subject of the call, I don’t know. I let her talk until she needed to take a breath, then interjected, “May I give you more information?” each time this occurred, until finally my message was delivered, and we got to work on the real problem.

Why would I devote so much time to this phone call? Because I needed the services of the receiver on the other end of the phone. Interrupting her abruptly to tell her how busy I am, using a smug tone of voice, or getting angry would simply slow down progress, and patient care. Giving good phone requires a purpose, an intended outcome, and patience.

What is your biggest peeve about telephones at work? How does your unit help patients seeking information by telephone?

A version of this post was previously published on TheONC.org.

Are Nurses Attracted to Gardening Because We Work in Close Proximity to Death?

On a beautiful late spring morning, I sat in my favorite chair, sipping coffee and writing. Through the window, I watched a hummingbird sip from the newly-potted salvia on our tiny deck. He is so at home that he actually perched on the railing while drinking from the tubular blossoms.

Hummingbird by jparadisi

Hummingbird by jparadisi

It was satisfying to watch. The hummingbird’s presence deepened my enjoyment of our small container garden.

Years ago, before changing course to make time for painting and writing, I had a huge garden. The limitations of container gardening make me miss my ambitious gardens of the past. As I write, I imagine a larger garden after I retire from nursing, whenever that may be.

What is the connection between nurses and gardens? I don’t think I know a nurse who doesn’t grow something, if only a lowly houseplant on a windowsill. Every spring, it’s common to find potted plant starts in the staff room from one nurse’s garden brought for another nurse to plant. I know nurses who raise prize-winning orchids. Another farms trees in his spare time.

Are we attracted to gardening because we work in close proximity to death? Does placing a dormant seed into carefully prepared soil, waiting for it to burst forth and blossom, satisfy something in our souls, deeper than merely beautifying our homes?

Nurses wear gloves to prevent soil from staining our fingers, keeping them from seeming unsightly as we palpate a patient’s vein to start an IV. Still, garden soil often seems cleaner, more wholesome, than the invisible bacteria populating the skin of human beings.

At work I overheard nurses giving one another advice on killing garden slugs. I was horrified when one said she snips them in half with garden shears. However, a few days later, when I found one in my container garden, I didn’t think twice about dowsing the poor creature in salt. Encrusted, he reared up, pillar-like, then moved no more. Was my action any less cruel because it evokes the Biblical image of Lot’s Wife? Are my coworkers and I applying oncology principles to gardening: both tumors and slugs must be removed, either through cutting (surgery) or by chemo?

My final observation about nurses and gardening is this: how little nurturing we are inclined to lend a plant for its survival. Universally, I hear, “If it doesn’t live, it’s not meant to be,” and I share this sentiment about plants. I wonder if nurses have such low tolerance for a plant’s inability to thrive because we give so much of our hearts to our patients?

Nursing Interruptions: When the Light Gets in Your Eyes

Running through Portland’s Water Front Park for exercise one morning, the sun silhouetted a Coast Guard helicopter flying low over the river. The loud noise of its rotating blades captured the attention of a group of preschoolers playing nearby in the grass.

by jparadisi

by jparadisi

The children stopped to watch the helicopter, but the bright sunlight behind it glared into their eyes so they turned away and resumed their activities — except for one three year-old boy, who held one hand before his eyes, using it as a filter to block the intense light of the sun. This allowed him to stay focused on the helicopter while it glided through clouds and blue sky.

I carry this image in my mind’s eye and pull it out often, like now, while writing this post, distracted by checking Facebook updates, emails, and shopping an online department store sale. I remind myself to focus on the job at hand, like the preternaturally wise three-year old.

For nurses, the need to focus is critical, and the distractions more numerous. In fact, multitasking while performing patient care is encouraged among nurses as a job skill, with mixed results.

According to a 2010 article posted in Medscape Medical News, nurses that are interrupted during medication administration run a risk of making an error:

For each interruption, there was a 12.1% increase in procedural failures and a 12.7% increase in clinical errors, with the association between interruptions and clinical errors independent of hospital and nurse characteristics. More than half (53.1%) of all administrations were interrupted (95% confidence interval [CI], 51.6% – 54.6%), and nearly three quarters of total drug administrations (74.4%; n = 3177) had at least 1 procedural failure (95% CI, 73.1% – 75.7%).

Teamwork requires the flexibility to prioritize the needs of patients against the needs of unit workflow. Nurses need some sort of filter for incoming stimuli so that the essentials — like medication administration — are sorted from interruptions that can wait. Even for nurses with strong prioritization skills, many shifts pass in which no single task is completed from beginning to end without interruption.

Multitasking is as much a team sport as it is a personal responsibility. For instance, when checking medications, particularly chemotherapy, it’s helpful if the team withholds unrelated interruptions from the nurses checking chemo until after the check is completed. Providing a separate space such as a medication room would prevent interruption, but not all clinics or hospitals have the luxury of this much vacant real estate.

To decrease interruptions, some hospitals distribute badges that flash an LED light alerting coworkers when a nurse is in the midst of medication administration. If this works, I’m afraid that the temptation to keep the light flashing my entire shift would overwhelm me.

What are your suggestions for decreasing interruptions during medication administration? Does your institution provide a medication room or use other indicators to prevent interruptions while checking chemotherapy? If so, does it work?

This Week: EHRs & The Nurse’s Voice, Collusion & A Nurse Asks for Help

A physician, standing in a busy hospital unit, was overheard telling a resident,

“If you want to be certain something gets done for your patient, find the busiest nurse in the unit, and ask her to do it.”

It’s true, nurses thrive on getting the job done.

Here at JParadisiRN blog, things are hopping. Besides transitioning to a new employment opportunity, I’ve been busy writing, and making art.

In case you missed it, Do EHRs Rob Nurses of Voice and Oversimplify Descriptions of Patient Care? is the title of my latest post for Off the Charts, the blog of the American Journal of Nursing. While I mostly love EHRs, the voice of bedside nursing is lost by reducing the nurse’s note to check boxes and smart phrases. However, not everyone agrees. What’s your opinion? BTW, the I made the collage illustrating the post; the text is from Florence Nightingale’s Nursing Notes.

Weekly, I write and illustrate a post for TheONC, The Oncology Nurse Community website. This week’s post, Which Came First, The Chicken or the Nurse? ponders the lack of privacy and personal space for nurses.

Chapter 13 of The Adventures of Nurse Niki is posted. In  Collusion, Niki’s creative solution for managing her patient’s under medicated post-surgical pain last week yields an unexpected result, in which she coaches a father how to ask his daughter’s surgeon to treat her pain. How do you handle similar situations?

I receive comments from nurses, some asking questions. A recent comment submitted to an older post, Of Medication Errors and Brain Farts is a single line,

I made a med error and lost my job how do you go on

If the comment touches you, please reach out with support and advice for this nurse in replies to this comment. Let’s help out a fellow nurse, yes?