It never fails. I've promised The Husband I'll leave work by 1500 and it's now 1515. A nurse comes in to talk to me about an idea.
"Why don't we have a senior corpsman designated for each shift to check the work of the other corpsmen? That way all the I's and O's will be done, vitals will be recorded, and everything else will be covered."
"That's a good idea," I say. "Unfortunately, I only have two corpsmen scheduled for most shifts. You're asking one corpsman to essentially do double work. This might also develop resentment in both corpsmen as one does extra work and the other feels he or she can't be trusted to get the work done. I think the nurse should double-check the work of her corpsman."
Silence falls as we both ponder these ideas.
"You're probably right," he finally admits. "I hadn't considered only two corpsmen on each shift."
I then explained that our highly trained and motivated corpsmen would be transferring to other units within the hospital over the next few months. "They only have two years here, so we get them for a year and then they go somewhere else for training diversity."
All the corpsmen we currently had on the floor had arrived between late June and August 2006. I'll be losing them soon and getting a fresh crop in to train. My senior chief keeps me maxed out on corpsmen with the understanding that when he asks for one by name, I have to give him or her up. He will ensure I have a body waiting in the wings and I have to trust him on this. If I stubbornly hold on to that corpsman until the last minute, there may be no body waiting and I am now short-staffed.
"I never realized that," the nurse said.
I suddenly understood that I don't communicate the pressures I face in my daily Division Officer juggling. Maybe I'm doing such a good job I make it look effortless. I doubt that. Perhaps, as in Benner's Novice to Expert, my nurses are not proficient yet. The sole measure of success for them is completing all nursing tasks. For some, it's simply surviving another shift. I realized I do an abysmal job of mentoring and leading these nurses. On a med-surg ward where nurses have no desire to be med-surg nurses, this is a particularly difficult challenge. I guess it's time to implement the "Bloom where BUPERS plants you" strategy. And time to talk with these nurses one-on-one.
"I'd like to sit down with you to discuss what you'd like to get out of MSU while you're here," I tell the nurse. "Let's talk when I get back from leave."
Saturday, May 5, 2007
Escaping the Dead End Corridor
Even though I'm on leave, I still went in to work today. I had the doctor look at The Son's induration (it was healing), I physically signed out on leave, and I reviewed my email and action items. I compiled statistics and submitted the monthly Division Officer report because I wouldn't be back before the deadline. I fretted about sending one of the corpsmen to the ICU.
Ultimately, the corpsman I decided on was the result of my reading Marcus Buckingham's book, "Now, Discover Your Strengths." If this corpsman sees something that needs to be done, rather than finding a junior corpsman to take care of it, he simply does it himself. He knows a lot from his year on the floor, he has college experience, and he is older and dedicated to the Navy as a career. His strengths are his maturity, his ability to take initiative, and his clinical skills and expertise.
His weakness, as he relayed to me, is his inability to delegate. "It's just easier and faster to do it myself," he said.
I have identified two concepts here:
1. Many times it IS much easier to do it yourself. Picking up litter and answering the telephone are low-level tasks that require no additional training beyond common sense and commitment to teamwork.
2. You should always be training your replacement. There was no need for me to submit a report while on leave. I should have trained someone else to do it. I have to explain where to find the data for the reports and how to update the charts. I have to obtain permissions for the other person to be a contributor online. I have to show them how to review and respond to requests for additional information from higher-ups. I haven't done any of that and it's only a monthly report, so I also need to generate a "how-to" for my desktop reference, "Instant Division Officer Handbook - just add respirations."
I've shoved fistfuls of paper into this 3-inch binder and I haven't organized anything and I haven't made it easier for the next person to step into my shoes. When I first arrived here, I dutifully noted the heavily stenciled warning above the double doors: Dead End Corridor No Exit. I joke that the sign leading to my office is a self-fulfilling prophecy. Well, it will be if I don't start training my replacement now.
Ultimately, the corpsman I decided on was the result of my reading Marcus Buckingham's book, "Now, Discover Your Strengths." If this corpsman sees something that needs to be done, rather than finding a junior corpsman to take care of it, he simply does it himself. He knows a lot from his year on the floor, he has college experience, and he is older and dedicated to the Navy as a career. His strengths are his maturity, his ability to take initiative, and his clinical skills and expertise.
His weakness, as he relayed to me, is his inability to delegate. "It's just easier and faster to do it myself," he said.
I have identified two concepts here:
1. Many times it IS much easier to do it yourself. Picking up litter and answering the telephone are low-level tasks that require no additional training beyond common sense and commitment to teamwork.
2. You should always be training your replacement. There was no need for me to submit a report while on leave. I should have trained someone else to do it. I have to explain where to find the data for the reports and how to update the charts. I have to obtain permissions for the other person to be a contributor online. I have to show them how to review and respond to requests for additional information from higher-ups. I haven't done any of that and it's only a monthly report, so I also need to generate a "how-to" for my desktop reference, "Instant Division Officer Handbook - just add respirations."
I've shoved fistfuls of paper into this 3-inch binder and I haven't organized anything and I haven't made it easier for the next person to step into my shoes. When I first arrived here, I dutifully noted the heavily stenciled warning above the double doors: Dead End Corridor No Exit. I joke that the sign leading to my office is a self-fulfilling prophecy. Well, it will be if I don't start training my replacement now.
Mary K & and Terrible, Horrible, No Good, Very Bad Day
We made bedside rounds that morning and one of the patients TOW'd from the ICU two days earlier was reporting a headache. Since that's one of my specialties, I asked, "Is this headache like headaches you've had before?" She said yes, and she treated it with Tylenol. We promised to get her relief. The plan was to discharge her home the next day.
Subconsciously we knew she just wasn't right, because everyone checked on her frequently. She started vomiting and told us it was related to the headache. Her only PRN medication besides Tylenol was MOM. She refused offers for us to get Zofran or phenergan. The doctor had ordered a doubling of her lisinopril dose and I reviewed the side effects. I went back to her room.
"Have you been taking lisinopril long? Did your headaches start with the addition of lisinopril?" She considered the question, and said no, the headaches started long after that. She was sitting in the chair, leaning her head against her hand, resting her elbow on the rolling table. "How bad is the pain?" She replied, "It's a 2." I went back to the med room and saw that I could at least give her another dose of Tylenol.
She never got it. When I returned to her room, the ward clerk was holding her hand and calling her name. She was splayed out in her chair, with her head at an odd angle. She was on telemetry so I ran for the bat phone to the ICU and told the listener on the other end to start recording strips. The LPN called for a code. The corpsman and I raced the crash cart down the hallway. We dragged her chair over to the bed where we lifted her up and laid her flat, her eyes open wide and drool running from the left side of her mouth. We opened the crash cart as the code team came up the back ladderwell from the ER. The other floor nurse was assisting with the efforts, so I stayed outside the room and managed the rest of the floor.
Another patient's oxygen saturation levels were dropping to the low 70's. His ABG's showed severe acidosis and the hospitalist went in to deliver the bad news to the patient and his wife. My patient had a final request so I had the legal officer get a lawyer from Big Navy to come and do a deathbed will. I witnessed his signatures on all the forms and when we were done, they had already taken the other patient away.
Without the bed, the room was cavernous. Crumpled 4x4 gauze and blood smeared the floor where they started an EJ instead of wasting time searching her non-existent antecubital veins. A freshly spiked and primed infusion set dangled on the edge of the trash can, unused. The chair had been shoved into the corner. It was a rave gone bad.
Back when I first started nursing, one of my intern friends coined a term: the Grillo sign. Practically everything in healthcare is objectively measured or assessed and identified by signs---Obturator or Psoas Signs, drawer sign, or Homan's Sign. For Dr. Grillo, this meant the radiologist didn't have to point out the abnormality on the films; the defect or problem was readily apparent, often at some distance from the viewer.
This patient stroked out. The signs were there. She'd reported nausea over the past few days and other non-specific or vague symptoms. Only a few tools exist for treating stroke on Guam: medications like mannitol to reduce brain swelling and vasoactives to control blood pressure, drilling holes in the skull to relieve swelling (a very bad sign), and prayer. These patients are not stable enough to medevac to Hawaii or Japan. And rehab is extremely limited for those who survive.
Would identifying her problem earlier have made a difference? I repeated this story so many times that day, to myself and to others who patiently listened, who must have been reminded of "what ifs" in their own careers as healthcare professionals. As others reassured me, everything had already been set in motion long before I assumed her care that day.
Ultimately, the long slow bleed filled the right ventricle of her brain. And now, it is a waiting game, as it is for the patient with lung cancer, while we wait for the next terrible, horrible, no good, very bad day.
Subconsciously we knew she just wasn't right, because everyone checked on her frequently. She started vomiting and told us it was related to the headache. Her only PRN medication besides Tylenol was MOM. She refused offers for us to get Zofran or phenergan. The doctor had ordered a doubling of her lisinopril dose and I reviewed the side effects. I went back to her room.
"Have you been taking lisinopril long? Did your headaches start with the addition of lisinopril?" She considered the question, and said no, the headaches started long after that. She was sitting in the chair, leaning her head against her hand, resting her elbow on the rolling table. "How bad is the pain?" She replied, "It's a 2." I went back to the med room and saw that I could at least give her another dose of Tylenol.
She never got it. When I returned to her room, the ward clerk was holding her hand and calling her name. She was splayed out in her chair, with her head at an odd angle. She was on telemetry so I ran for the bat phone to the ICU and told the listener on the other end to start recording strips. The LPN called for a code. The corpsman and I raced the crash cart down the hallway. We dragged her chair over to the bed where we lifted her up and laid her flat, her eyes open wide and drool running from the left side of her mouth. We opened the crash cart as the code team came up the back ladderwell from the ER. The other floor nurse was assisting with the efforts, so I stayed outside the room and managed the rest of the floor.
Another patient's oxygen saturation levels were dropping to the low 70's. His ABG's showed severe acidosis and the hospitalist went in to deliver the bad news to the patient and his wife. My patient had a final request so I had the legal officer get a lawyer from Big Navy to come and do a deathbed will. I witnessed his signatures on all the forms and when we were done, they had already taken the other patient away.
Without the bed, the room was cavernous. Crumpled 4x4 gauze and blood smeared the floor where they started an EJ instead of wasting time searching her non-existent antecubital veins. A freshly spiked and primed infusion set dangled on the edge of the trash can, unused. The chair had been shoved into the corner. It was a rave gone bad.
Back when I first started nursing, one of my intern friends coined a term: the Grillo sign. Practically everything in healthcare is objectively measured or assessed and identified by signs---Obturator or Psoas Signs, drawer sign, or Homan's Sign. For Dr. Grillo, this meant the radiologist didn't have to point out the abnormality on the films; the defect or problem was readily apparent, often at some distance from the viewer.
This patient stroked out. The signs were there. She'd reported nausea over the past few days and other non-specific or vague symptoms. Only a few tools exist for treating stroke on Guam: medications like mannitol to reduce brain swelling and vasoactives to control blood pressure, drilling holes in the skull to relieve swelling (a very bad sign), and prayer. These patients are not stable enough to medevac to Hawaii or Japan. And rehab is extremely limited for those who survive.
Would identifying her problem earlier have made a difference? I repeated this story so many times that day, to myself and to others who patiently listened, who must have been reminded of "what ifs" in their own careers as healthcare professionals. As others reassured me, everything had already been set in motion long before I assumed her care that day.
Ultimately, the long slow bleed filled the right ventricle of her brain. And now, it is a waiting game, as it is for the patient with lung cancer, while we wait for the next terrible, horrible, no good, very bad day.
Disruptive Physician Behaviors
My patient was convinced he was on a regular diet. "I can't eat jello and broth for breakfast," he said. "The doctor said I could eat real food today."
His diet orders were written"clear liquids." I paged the surgeon, a difficult task to do at 0900 on Sunday morning. He didn't return my page. I paged again and finally left a message on his cell phone at 0945. Good thing it wasn't an emergency.
He finally returned my call at 1015.
"I need orders for a regular diet," I said.
"He has orders. I ordered it when he was transferred from the ICU."
"No, sir, he doesn't. The only orders are for a clear liquid."
"Fine, give him a regular diet." Slam.
I went ahead and ordered a 2000 ADA diet (which should really be "carbohydrate-consistent" but just try re-writing deeply ingrained institutional habits) instead of a regular diet and didn't page him back to request a correction because he'd just slam the phone down again. We both knew what he meant.
Unfortunately, I had to page him later, this time for a patient experiencing bladder spasms. I have learned to be concise with the surgeon because he becomes impatient. I explained the patient was feeling the urge to bear down and urinate and was telling himself not to do it.
"He already has Ditropan ordered," he said.
"No, sir, he doesn't."
"Well, the urologist ordered it yesterday."
"No, sir, he didn't. When he came to examine the patient, the symptoms were not consistent with bladder spasms and he consulted YOU for input to give a one-time order for morphine and start around-the-clock Toradol."
"Fine. Ditropan 5 mg po TID." Slam.
Barely time to do a read-back and verification. Good thing I have a thick skin and lots of experience with surgeons. I never take anything personally because they're just operating (ha-ha) on a higher plane.
Unfortunately, I have a lot of junior nurses who don't have this experience and they are terrified to call for assistance, to request clarification, to ask for guidance, because the surgeon will condescend, belittle, and in some cases, yell at them. This surgeon is going on leave for two weeks in May. Maybe he'll come back a little less stressed, a little more rested. Then again, surgeons are a different breed from the rest of us---highly driven and deeply superstitious but skeptical perfectionists with poor bedside manners.
In the nurses' station, I laughed and repeated a comment made by the infectious diseases specialist regarding one of my patients whose oxygenation levels hover around 66%: "He's a
facultative anaerobe."
This surgeon overheard me and said, "That's mean. Even if it's the Department Head for Medicine, you shouldn't repeat things like that. That's just mean."
I don't think he grasps the irony.
Disruptive Physician Behaviors
Disruptive Physician Behaviors - Rhode Island
Practicing Excellence
"A healthy physician-nurse relationship is not just a nice thing to have; it is a competitive advantage driving clinical outcomes, patient safety, and staff retention. Interviews of nurses demonstrate that when physicians intimidate and behave disruptively, clinical care is impacted. Ninety-two percent of hospital-based nursing staff have witnessed disruptive physician behaviors and report a compromise in communication, collaboration, and information transfer. Nurses also reported disruptive physicians increase frustration, stress, and the quality of workplace relationships. When respectful, collaborative physician-nurse communication is in place, and nurses are encouraged to speak up in the face of patient danger, errors are reduced and care for patients improves.
“The physician’s role in workplace operations and performance is critical,” says Beeson. “Physicians are in a leadership position and will influence the perception, attitudes, and behaviors of others. A vested physician committed to reward and recognition, who clearly articulates expectations, who gets to know and takes care of staff, and models the behaviors consistent with their organizational mission, will create a high-performing unit.”
His diet orders were written"clear liquids." I paged the surgeon, a difficult task to do at 0900 on Sunday morning. He didn't return my page. I paged again and finally left a message on his cell phone at 0945. Good thing it wasn't an emergency.
He finally returned my call at 1015.
"I need orders for a regular diet," I said.
"He has orders. I ordered it when he was transferred from the ICU."
"No, sir, he doesn't. The only orders are for a clear liquid."
"Fine, give him a regular diet." Slam.
I went ahead and ordered a 2000 ADA diet (which should really be "carbohydrate-consistent" but just try re-writing deeply ingrained institutional habits) instead of a regular diet and didn't page him back to request a correction because he'd just slam the phone down again. We both knew what he meant.
Unfortunately, I had to page him later, this time for a patient experiencing bladder spasms. I have learned to be concise with the surgeon because he becomes impatient. I explained the patient was feeling the urge to bear down and urinate and was telling himself not to do it.
"He already has Ditropan ordered," he said.
"No, sir, he doesn't."
"Well, the urologist ordered it yesterday."
"No, sir, he didn't. When he came to examine the patient, the symptoms were not consistent with bladder spasms and he consulted YOU for input to give a one-time order for morphine and start around-the-clock Toradol."
"Fine. Ditropan 5 mg po TID." Slam.
Barely time to do a read-back and verification. Good thing I have a thick skin and lots of experience with surgeons. I never take anything personally because they're just operating (ha-ha) on a higher plane.
Unfortunately, I have a lot of junior nurses who don't have this experience and they are terrified to call for assistance, to request clarification, to ask for guidance, because the surgeon will condescend, belittle, and in some cases, yell at them. This surgeon is going on leave for two weeks in May. Maybe he'll come back a little less stressed, a little more rested. Then again, surgeons are a different breed from the rest of us---highly driven and deeply superstitious but skeptical perfectionists with poor bedside manners.
In the nurses' station, I laughed and repeated a comment made by the infectious diseases specialist regarding one of my patients whose oxygenation levels hover around 66%: "He's a
facultative anaerobe."
This surgeon overheard me and said, "That's mean. Even if it's the Department Head for Medicine, you shouldn't repeat things like that. That's just mean."
I don't think he grasps the irony.
Disruptive Physician Behaviors
Disruptive Physician Behaviors - Rhode Island
Practicing Excellence
"A healthy physician-nurse relationship is not just a nice thing to have; it is a competitive advantage driving clinical outcomes, patient safety, and staff retention. Interviews of nurses demonstrate that when physicians intimidate and behave disruptively, clinical care is impacted. Ninety-two percent of hospital-based nursing staff have witnessed disruptive physician behaviors and report a compromise in communication, collaboration, and information transfer. Nurses also reported disruptive physicians increase frustration, stress, and the quality of workplace relationships. When respectful, collaborative physician-nurse communication is in place, and nurses are encouraged to speak up in the face of patient danger, errors are reduced and care for patients improves.
“The physician’s role in workplace operations and performance is critical,” says Beeson. “Physicians are in a leadership position and will influence the perception, attitudes, and behaviors of others. A vested physician committed to reward and recognition, who clearly articulates expectations, who gets to know and takes care of staff, and models the behaviors consistent with their organizational mission, will create a high-performing unit.”
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