Novice to Expert

Developing a Courageous Workplace

2011-03-25T17:26:00.000-07:00

I am inheriting a dysfunctional clinic. One nurse is creating a hostile work environment and another nurse has resorted to communicating only by email to this nurse so she can limit her interactions. A clerk has "borrowed" over $1000 from her co-workers over the past year and HR says nothing can be done, that these "loans" could be considered "donations." I get ownership in May, but I am already pondering solutions.

I thought this article on workplace courage from the Center for Creative Leadership might provide some ideas for action.

According to the article, people in a courageous workplace:

•Take on more challenging or complex projects.
•Actively seek out tasks that stretch their skills.
•Speak up more frequently, forcefully and truthfully.
•Be less risk-averse, less self-conscious and less apathetic.
•Do less brownnosing and complaining.
•Get more work done.

That sounds good to me. A hostile work environment can cost a lot of money in recruitment and retention and lost productivity. So, one of the options I proposed to the current leader was the development of a code of conduct by the staff. I also proposed requesting a mediator from HR interview and evaluate the interactions of these workers for an unbiased opinion. Coming from a high-functioning unit and feeling quite competent, this clinic will provide quite the turn-around challenge.

Am I feeling courageous?

Enchantment

2011-03-08T05:21:00.000-08:00

Well, it's official. I took the quiz and I scored very well. I am certified enchanting.

The Last Five Minutes of the Day

2011-02-21T22:14:00.000-08:00

With the increasing workload, I would come in to work and be overwhelmed with the areas and issues that needed my attention. So, I started doing a to-do list at the end of the workday. That worked pretty well, except I had items that were left undone and carried over to the next day for extended periods of time. Taking a good hard look at this meant acknowledging that either 1) the task was not that important (to allow it to lie undone for so long) or 2) it was too huge to process. I had to break big tasks down into manageable steps I could actually demonstrate to my fearful self that the big project could be done.

I recently found another way to better use those last few minutes of the workday from the Harvard Business Review Blog:

Every day, before leaving the office, save a few minutes to think about what just happened. Look at your calendar and compare what actually happened—the meetings you attended, the work you got done, the conversations you had, the people with whom you interacted, even the breaks you took—with your plan for what you wanted to have happen. Then ask yourself three sets of questions:

•How did the day go? What success did I experience? What challenges did I endure?
•What did I learn today? About myself? About others? What do I plan to do—differently or the same—tomorrow?
•Who did I interact with? Anyone I need to update? Thank? Ask a question? Share feedback?

This is a pretty good tool for prioritizing the next day's tasks as well as for growing and maintaining relationships.

Apologies can be unsatisfying

2010-11-23T08:44:00.000-08:00

My boss came to me yesterday afternoon and asked how the morning had gone. Then he held out customer service card where one of my colleagues in another department had written a negative response about me.

Frustrated with what I perceived to be this person's inability to solve the problem, I grabbed the patient's ID out of his hand so I could pull up the online records. I immediately knew this was a mistake, but I didn't apologize. I wish I had. Instead, I softened everything from that point on, explaining everything I was doing and trying to be as helpful as I could be, hoping this person would see the grabbing as an anomaly.

He didn't.

So I told the boss I planned to apologize to this person.

Today, after the mad rush, I stopped by the lab. The technician immediately recognized me and ushered me into an office. It wasn't what I expected. I had actually planned to apologize in front of others so they would know I respected this person and that I was acknowledging my role in behaving badly. But, this must have been what he wanted and needed.

I told him I was sorry. I shouldn't have done what I did and I wouldn't do it again.

I asked him why he had submitted the comment card instead of talking to me. He said, "I wanted to bring it to your attention. I wanted to make sure you weren't treating your junior sailors this way."

I then asked him why he didn't call me on my behavior at the time. "I recognize there is a difference in rank," I told him, "but if you were justified, as both of us know, then what was the point of not calling me on it there in front of those junior sailors? Wouldn't that have been a more powerful example of how to role model behaviors for those sailors?" Truth should be able to speak to power.

He didn't seem to understand what I was trying to say. "Would you like me to do anything else? Do you need anything else from me?" I asked. It didn't seem nearly enough. Perhaps the apology and my presence were all he wanted and that would suffice, but for me, it was very unsatisfying.

I talked to my boss this afternoon and told him I apologized to the lab technician. I also explained that it didn't help me; I knew I was wrong, but the apology didn't meet MY needs. I didn't know if it was the inequality in status or the cultural differences, but I needed something more.

I have a problem with trying to speed things up and can adopt a tone of voice that irritates people or suggests condescension. I suggested to my boss that perhaps I could ask my colleagues to help me identify when I'm getting to close to the edge by using some code word to help me step back from the situation and regain control of my feelings and actions.

"It could be helpful," he acknowledged. "That's the principle behind 360 degree evaluations." But he left it up to me to broach the topic with my subordinates. So that's my plan for tomorrow as I begin my trek toward a more mindful workplace.

Leadership Tied to Maturity and Receptiveness

2010-09-22T03:02:00.001-07:00

So I spent my lunch hour composing an email response loaded with what I thought were leadership newsletters, books, and articles, along with the observation I was not a great leader. I also stated I did not have to be the expert; I only needed to know who was and to let him or her shine. I read it through several times to make sure there were no errors, that nothing could be miscontrued or misunderstood, and sent it off, full of hope that everything would be made as new as I wrote in one sentence: a clean slate to start again.

I sent the email at 1244. I received a response at 1250. Six minutes. And the response? Ma'am,
Noted. Thank you for your time.

In my mid-to-late 20's, I might have had my own image tied into what and how I wanted to be perceived by others. Maybe I would have responded with the same speediness, the same acerbity, the lack of depth and gratitude. And maybe that's my error---in thinking she would be grateful.

Well, maybe someday she will be. I can hope.

A Little Like Dying

2010-06-17T14:41:00.000-07:00

I've known for a few months now I will be deploying. Pretty much in denial for the first few months, I was able to tolerate this and, because of the chaos and uproar at work, almost welcomed the respite from the Beltway drama and politics.

That changed as I got my anthrax shot (which laid me low) and I avoided a smallpox vaccination because of some mysterious dermatitis on my collarbone. All of a sudden I have less than 28 days left on this side of the world, no childcare plan in place yet, and overwhelming grief that I have not been able to accomplish all I set out to do in my assignment as the department head of surgical nursing.

In leaving for the unknown with hopes of returning, I understand my grief is due to changes beyond my control. I won't be returning to this same position. I can't; someone else will have stepped in to take the helm. So what will I do when I come back? Will it be as challenging? Will I like it? Will it be---dare I say--fun?

I've been keeping in touch with one of my JG's in Kandahar who has excelled and is over half-way through her deployment. "What do you want to do when you get back?" I asked, hoping she would want to stay and provide leadership and expertise on the unit.

"I'd like to go to the APU or PACU," she wrote. "I've been working on the wards and assisting with trauma, which can be rewarding but draining. I'd like a break."

So, I asked her if she'd considered becoming an OR nurse; would she have time to shadow a nurse there? She'd have the opportunity to provide attention to detail, work as a team, and monitor patient safety. "It provides some distance from the patient," I suggest.

As an Individual Augmentee (IA), I am plucked from my workplace and sent alone (mostly) to meet up with other individuals to form a tribe of providers to do a job far away from our families and support networks.

I've had lots of people ask me over the past two weeks: Are you okay?

"Yes," I say. "I think so."

Sparta Humor Very Similar to Healthcare Humor

2009-07-20T23:07:00.000-07:00

The Spartan Sense of Humor by Steven Pressfield is very similar to that found in First Responders and Healthcare Workers. I love what he writes:

["T]hey’re not jokes. They’re not meant just to raise a laugh. Yet they’re funny, they’re on-point. Second, they don’t solve the problem. Neither remark offers hope or promises a happy ending. They’re not inspirational. They don’t point to glory or triumph–or seek to allay their comrades’ anxiety by holding out the prospect of some rosy future outcome. They face reality. They say, “Some heavy shit is coming down, brothers, and we’re going to go through it.”

That could be said about a lot of workplaces right now...

Use Your Peripheral Brain

2009-07-15T21:56:00.000-07:00

Today was a Command Urinalysis. Usually, that's not a problem, just an inconvenience. However, my name was on the list, I had requested this morning off due to another appointment, and the instructions on the Command Urinalysis list stated that a memo attesting to the individual's unavailability for this random urinalysis was insufficient. Members needed to provide copies of special liberty chits, memorandums, and leave or TAD paperwork.

Incredible. The one morning I am not at work, all bedlam breaks loose. The LPO, instead of requesting assistance from more experienced officers, directs his junior enlisted to generate a special lib chit for me and backdate it. Not a good idea. Besides, officers don't routinely route special request chits; they generally draft memos or letters requesting time off. The fact of the matter is, this wasn't an incident that would require written notification.

So, my LPO decided his brain power was sufficient for responding to this situation. If he had been on "Who Wants to be a Millionaire," he probably would have lost his opportunity to win. Steven Shapiro has a better answer and one this LPO can employ now and for future emergenices.

Typically, "Who Wants to be a Millionaire" allows you to use all your accumulated knowledge to answer questions of increasing difficulty and esoterica. You may finally get to a point where you can no longer weed out obvious distractors and have exhausted your personal information fount. That's where consulting others comes in handy.

Phone-a-Friend only works if your friend is more knowledgeable than you. In the Navy, people who are consulted by others are usually Sea Lawyers. That is not a popular moniker.

In Fifty-Fifty, two of the answers are removed. However, if you have no answers or you know that the answers you do have are probably not right, this option doesn't help.

Ask the Audience is a little better, but again, it relies too heavily on the knowledge of the crowd. As with 50-50, if you don't know your options or you know what you do have is not correct, asking your audience won't be helpful.

Finally, Ask the Expert. This is what I told the LPO to do for future problems. For one thing, consulting with someone who has considerably more experience will provide a lot more viable options. Also, the expert will tend to have more rank and authority to take the heat or to run interference for him.

In healthcare, many medical and nursing students have notecards, crib sheets, or PDAs to scribble the information they need at fingertip notice and they refer to these bits of data as their peripheral brains. In the business world, they call it networking---using people (and their collective knowledge) to find answers and get ahead.

Wind Mills and Flail Exercises

2009-05-22T17:53:00.000-07:00

I have two months left and it is hard to summon the strength to continue to rail against waste and indifference. Six months from now it will be as though I never set foot here. And you know what? I have come to the conclusion that having the military run hospitals is stupid because we have a new Commanding Officer every two years and the status quo has to be shaken up, corporate knowledge must be lost, and politics must be endured, because no CO ever gets ahead by continuing to do what his or her predecessor has done (even if it is succeeding wildly---which has not been the case, unfortunately).

I am aghast at the amount of corporate knowledge I have accumulated and the fact that I cannot possibly communicate all the information for one-of-one situations that have happened so someone else doesn't have to reinvent the wheel or undergo a flail exercise (FLAILEX). Quite frankly, I don't think I've truly amassed such founts of information so much as I've discovered my network of people who know or who know other people who know the information I need. The biggest problem with functioning where I am is being surrounded by people who feel they must know everything and if they don't know it, there is no one else who can possibly know what they need to know. It is silo-ization at its finest. [In 2002, Vicki Casey, program director of Information Highways, used the word "siloization" to describe the smokestack-like structures that promote knowledge hoarding, rather than knowledge sharing and collaboration.]

Case Study
The LPO needed to get a bile bag (don't ask) from the OR. He called us in the endoscopy suite and said the OR tech didn't know what he was talking about. Instead of telling the OR tech, "Look, is there someone else I can talk to?," the LPO calls us. And instead of the OR tech being creative and helpful, he stops at the "Dude, I have no idea what you're talking about. End convo."

The inability to think creatively is not limited to the enlisted ranks. I had another Division Officer approach me for information about wound care. I'm not an expert. I only read the labels (but I did sleep at a Holiday Inn Express last night). So I look through the Phone Book and call healthcare agency who accepts patients from our hospital. I ask to talk to someone about wound care. They transfer me to Sofia. Sofia walks me through the steps, I transcribe them, and I hunt down the products (unfortunately, we don't have a few, so I direct my Supply Petty Officer to order them). I give the instructions to the Division Officer, note the telephone number and name for her in case she has future questions, and make a mental note to bring my corpsmen up to speed on wound care supplies and information. It didn't take very long, maybe 15 minutes total, including a call to another hospital for their wound care specialist who wasn't due to work until later that afternoon.

Overcoming Defensiveness Key to Better Workplace Environment

2009-05-03T00:16:00.000-07:00

My LPO was being counseled by the Senior Enlisted Leader (SEL) for our directorate.
"Your problem is you're too defens---" was all he was able to get out before the LPO interrupted, saying, "No, I'm not!"

This occurred after he had already been brought in to my office to discuss progress on a self-improvement plan. In that discussion, the LPO could not get himself under control to stop talking, even after repeated and even rude requests to be quiet.

After his discussion with the SEL, he came to me and said he recognized he had a problem. "So if you see me bringing my hand to my mouth," he said. "That's my way of slowing myself down so I don't interrupt or respond right away."

I told him I was curious about when this defensiveness had started. "When I became a corpsman," he said. "People assume because I started out in another specialty, I don't have any medical knowledge." He pointed out several individuals, including the Department Head and a fellow surgical technician as culprits in minimizing his experiences and abilities. "Well," I said. "There are gaps in your knowledge and not everyone knows what they are. Isn't it better to assume you don't have an essential skill than to assume you do?"

In any case, I doubt his defensiveness just started when he became a corpsman. Argyris, a leader in adult education, believes defensiveness starts in childhood and is reinforced throughout life. However, he is taking positive steps to correct this behavior. As Jim Tamm, author of Radical Collaboration, says, recognizing defensive behavior is the first step. Dr Nathan Cobb, a psychologist and marriage therapist in Calgary, has a very good workbook on overcoming defensiveness. Although "How to Overcome Defensiveness" is directed towards marriage, my LPO admitted that he adopted a defensive attitude at home, too.

One of the important things I learned in our encounter that started this spiral was my own role. I chose to become angry when the LPO would not stop talking and, for that, I regret my responses. Ridge Training's Overcoming the Destructive Dynamics of Defensiveness could have helped me stop my inner Mr Hyde from erupting.

The second step is acknowledging the emotions that come with the awareness of defensiveness. In this case, the tenets of yoga (breathing) and Buddhism (mindfulness) are invaluable. The Miracle of Mindfulness by Thich Nhat Hanh looks promising. The link from YouTube provides mindfulness using movement.

This website provides information on using hypnosis to overcome defensiveness. I'll let you know how it goes.

Supervision is a lost art...

2009-04-08T03:34:00.000-07:00

A guest article written by Michael Taplin on Slow Leadership really resonated with me. His article, "The Lost Art of Supervision," discusses how everyone has become a leader, but we've lost our supervisors, the ones who tower over us to teach us what we must do, to hold us accountable to our responsibilities, and to remind us of our moral code.

Super article—a must read for anyone who wonders where they fit into the current world.

Mulligans Work in Healthcare, Too

2009-02-17T02:25:00.000-08:00

Lony C. Castro, professor and chairwoman of the obstetrics and gynecology department at Western University of Health Sciences, writes in the LA Times: If a doctor's visit is going badly, you can start over---Maybe the physician was distracted. Or spoke too quickly. Whatever the communication problem, take a deep breath and try again. Sometimes doctor and patient benefit from a second take.

This happened to me, although in an inpatient setting. The family was very angry because they had brought their mother to the ER--twice---with symptoms of a stroke. I couldn't understand why she wasn't admitted to the unit at the first visit so I was angry with the physician for putting me in this position. After a heated discussion with the daughter, I took a deep breath and said, "I'm sorry. I hate having to apologize for another healthcare provider's mistake. Can we start over?"

This was all it took to help them realize I was distressed by this injustice and we were in it together. I had some Red Dress pins in my office. When I was finished assessing the patient, I grabbed a handful and gave one to each daughter. I explained to them they were each at risk for stroke because of their mother's history and this was an opportunity for them to make lifestyle changes that could delay or prevent this occurrence for them.

Do-overs allow you to take a deep breath and start with a clean slate. If it's not your fault, then it allows the other person a little grace. And God knows, we can all do with a little of that now and then.

Processing Betrayal in the Workplace

2008-12-28T01:15:00.001-08:00

My Leading Petty Officer (LPO) decided to bail on mandatory training for the holiday. I did not realize this until one of my colleagues remarked, "You'd better tell your corpsmen to get back to work. They need to stop paging themselves out of training." I was furious and embarrassed.

I walked into the main office where all the HMs were sitting and talking and asked if everyone had attended training. One of the HMs said pointedly, "Some of us did, ma'am."

The LPO laughed.

I was speechless for a moment, then said, "What a great leadership example you set." I turned and walked back to my office. They went to lunch.

When the corpsmen came back, the LPO stuck his head in my office. "Ma'am, I just wanted to let you know that I took what you said to heart. I'll be going to the afternoon training session."

It has been several weeks and I am still angry about it. I don't understand why this still infuriates me. Part of the problem is this LPO is a cross-rate---he did not attain second class in the HM field, but exposure to the fleet should have impressed upon him the importance of setting the example and completing mandatory training, no matter how much a waste of time the training may be.

This article, Betrayed? 7 Steps for Healing, provides a good process to work through the feelings aroused by betrayal or a loss of trust. I'm pretty sure my HMs have already worked through the first step (Observe and acknowledge what has happened) and have moved on. The LPO came to my office and apologized for his behavior later that day so we've also accomplished step 2: Allow feelings to surface.

Step 3 says to Give employees support. I am still finding it difficult to be in the same room with this person---I feel uncomfortable in his presence...which makes me angry at myself. I sent an email message to him stating I was still available for mentoring and coaching, but he never responded, so I can only imagine he is just as uncomfortable.

In order for me to work through this, step 4 suggests Reframe the experience. In this step, I have to look at the role I played in this issue. Clearly, I did not have him think through the scheduling of training attendance: having all HMs but one at the morning session would not allow flexibility for emergencies within the clinic. In discussing this issue with the Senior Enlisted Advisor and the Department Head, I have realized that my leadership efforts and input are neither wanted nor desired. Asking myself questions like "How can I change my response?", "What choices or options do I have now?" or "What can I learn about myself and others from this experience?" gives me valuable insight into myself and my own actions and responses.

In step 5, they suggest I Take responsibility. I should ask myself, "What can I do now? What is in my control and what isn't? What can I do to make a difference?" In this case, I can simply give away control (ha! I never had it!) and refer questions on any clinic operations to the Department Head for action.

Step 6 is the hardest: Forgive. I must free myself of the anger, bitterness and resentment. "What needs to be said or done to put this issue to rest?" My biggest complaint here is the lack of communication and my lack of inclusion in clinic operations.

Finally, step 7 is Let it go and move on. As with Kubler-Ross's work on the stages of death and dying, I will not be able to accomplish these steps in order and all at once---it takes time. I love the model posted at the top of this article.

Click here for more information about the Reina Trust Building Institute and their book, "Trust and Betrayal in the Workplace: Building Effective Relationships in Your Organization, 2nd Edition (2008)."

Storytelling in Long Term Care Facilities

2008-11-22T19:38:00.000-08:00

This article really resonated with me. I truly believe in the value of storytelling and if stories carried actual physical weight, I would weigh a lot more than I did when I first started in nursing because of the patients' stories I carry with me.

This article from Provider Magazine, Creative Tasks Spark Imagination, outlines three techniques used in a long term care facility for residents along the continuum of memory impairments (from none to late-stage Alzheimer's or dementia). The first technique is based on Timeslips, which promotes social interaction. It helps to reduce the isolation that many persons with dementia may experience.

The second technique involves storyboarding which can be done by the resident or by the family, if the resident is not able to participate. Upon completion of the storyboard, a celebration is held to celebrate the individual's life.

In the third technique, individuals write their life stories in a 6-10 week storytelling workshop.

What I found most satisfying are the ending paragraphs:

"Many facilities have implemented these activities for their residents, and in some cases, reported increased wellbeing and cognitive functioning among participating residents. Implementing these creativity tools supports, encourages, and inspires residents, their families, and staff.

"These stories touch people in remarkable ways, no matter what age or ability."

I also found storyboarding for personal growth an interesting topic in itself. 37 Days discusses her experiences with storyboarding and this writer demonstrates how it can be done:

Storyboard Your Life

Get your own at Scribd or explore others: Literature Essays paper future

If Only It Were That Easy

2008-09-22T15:59:00.000-07:00

It was nearly 0900 when HM3 came to me and asked me if I had seen HM2 that morning.

"Why do you ask?"

"Well, his jacket is here and the light is on, but no one's seen him today. We've called his cell phone and it just rings and rings."

Dread consumed me. Today was the anniversary of LT Willman's death and it had been on my mind for the past week. "Do we have anyone we could send to his house?"

"We could have earlier, but now we're down staff."

"Let me see what I can do." I called his cell phone and it rang just as HM3 said. I found the recall bill with his landline phone and called it, saying I was worried about him and could he call back as soon as possible. I told the Department Head our HM2 was not available and I was going to call Base Security.

"Why not send one of the HNs?" he asked.

"Because if it's something bad, I don't want to wreck the corpsman."

I called Security and asked the Dispatch if they could send a patrolman to do a courtesy call for us. I explained that we had left messages on the HM2's cell phone and landline and HM2 was normally at work before all of us. I also explained that HM2 suffered from PTSD and his spouse was deployed. "Let me talk to the Watch Commander," she said. I waited on hold.

HM3 popped into the doorway. "HM2 just called. His dog knocked his cell phone off the table and he overslept." Relief flooded my brain and my shoulders relaxed. When the dispatch operator returned, I explained we didn't need their services after all.

When HM2 got into work, I sat down with him and talked to him about suicide. "You don't have to worry about me," he responded.

"But I do," I said. I told him about LT Willman and how he was the last person who anyone would have believed would die at his own hand. I still have his request for the PICC line course in a folder in my desk. Such a silly thing to hold on to. I used to drive by his house in the weeks following his death, looking at the yellow police tape barricading the doors. I told the psychiatrist that I did this. Why? he asked. I'm not sure, I said. I guess I believe that one of these times when I drive past, the yellow tape will be gone, and he'll be in his yard, waving and telling me, "No worries, ma'am."

No worries, ma'am.

Link to suicide screening for primary care clinics: Screening

Workers Leave Managers, Not Jobs

2008-09-20T21:10:00.000-07:00

From a nursing leadership perspective, the middle manager and his or her emotional intelligence are critical elements in recruiting and retaining nurses. Slow Leadership, one of my favorite blogs, features writing from Peter Vajda:

Twenty Indicators of Failing at Leadership

My favorite leadership failure indicators from his list:

Leaders who begin their responses to others’ suggestions or ideas with “no”, “but” or “however.”

This one happens all the time. Currently, my department is pushing through a space utilization request. I've had staff at every level of the approval process tell me, "You know that this space is already spoken for, right?"

Leaders who rationalize counter-productive processes, procedures and nonsensical bureaucratic practices by saying: “That’s just the way it is.”

Oftentimes, it takes more energy to keep the status quo than to consider an alternative. I wanted to do a replication research project when I first got here and was rebuffed. "It'll take too long to get the project approved."

Leaders who become defensive every time someone questions, or is curious about, one of their thoughts, beliefs or decisions.

Fortunately, we've had a regime change and it appears the newly-instated leadership is open and accepting, which was not middle management's experience with the previous occupants of the C-suite.

Leaders who are scattered, unfocused and unbalanced—be it mentally, emotionally or physically.

If you don't make a decision, then you can't be accused of making a bad decision, right?

Leaders who are a source of weakness, confusion and passing the buck in a stressful and uncertain environment.

My director scheduled a call to a specialist in a project I was working on. He commandeered the conversation and asked questions I already knew the answers to and failed to ask the questions for which I needed information. He made both of us look foolish and ill-prepared and wasted this other person's time.

Fortunately, Vajda also offers antidotes to these leadership problems through self-reflection with directed questions. I would encourage you to read them for personal insight and work. I know I used to consider being an expert clinician the height of professionalism. I'm coming up on the two-year anniversary of LT Willman's death and another well-respected nurse attempted suicide this past month. Real leadership is hands-on and messy.

So, how do YOU feel about the idea that “soft skills” are so important to defining your career as a successful leader?

Respect is a Two-Way Street

2008-09-11T02:13:00.000-07:00

We recently had the opportunity to ask questions of our senior leadership. With nearly everyone in our command seated in a large auditorium, it is intimidating to stand, state your name and workplace, then coherently state your question.

Several people stood and asked their questions and were answered politely with every response staying on message. Evidently, this senior leader had extensive media training and, as my husband remarked, didn't get this high by being stupid or making stupid comments.

At least, until I stood and asked my question. This senior leader look over my shoulder at someone then stared directly at me. "I see your director looks like he's sucking on a lemon," he said. He added, "And it's not a sweet lemon." He said a few more words about this lemon and my director's facial expressions, then started comparing our workplace and mission to our mainland counterparts who are also somewhat geographically isolated.

While my intent was certainly not to embarrass this official nor to make life difficult for myself, it served only to indicate the level of intimidation that is present in this type of environment and it also served to illustrate that these cattle calls require attendees to ask only those questions that are bland and inoffensive.

How much simpler would it have been to respond, "You know, that is an interesting question. I don't know the answer, but I will definitely look into it. Thank you for asking." I would have considered him to be a gracious and thoughtful leader who honestly and sincerely valued my input.

In this exchange, I lost face with my director for embarrassing him and I damaged my own credibility with my peers. On the other hand, this senior leader lost substantially more in the ridiculous comparisons between Guam, 29 Palms, Oak Harbor, and Lemoore. If a patient is taken to anyone of those hospitals and requires more comprehensive treatment, the patient can always be medevac'd, just as a patient can be medevac'd from Guam. But it takes at least 4 hours to fly to Okinawa and 7 1/2 hours to Hawaii...providing the patient and the airplane are ready to go right that minute. From 29 Palms you could be in Los Angeles or San Diego in considerably less than 7 1/2 hours...and you don't have to worry about altitude either.

Is This My Battle?

2008-08-26T03:47:00.000-07:00

I asked a corpsman to come from MSU to brief my corpsman on the Sailor of the Quarter Board for tomorrow. He brought his paperwork and instructed her on how to acquit herself properly and professionally. Then he sat down and that's when I noticed the glassy eyes. "I had a 101.6 degree temperature this morning," he said.

"Get yourself to sick call," I replied. "You need to be SIQ [Sick in Quarters]."

"I would, but the Division Officer said she would call in another corpsman to cover for me and those corpsmen have already worked three shifts."

He told me there were 8 patients and 3 would be discharged home. They had another nurse working who had been a corpsman herself, an LPN, a ward clerk, and an orienting corpsman. "That's more than enough to handle the workload," I said.

"That's what I thought," he said wearily as he forced his body out of the chair to return to the ward.

I thought of all the leadership books I've read, the ones I've made notes in, the ones I've loaned out. I sat in on the ranking board for the lieutenants and listened to the senior leaders ponder the limbo between being honest and being kind. This nurse is more concerned with herself, how she ranks among other nurses, and how she can accumulate collateral duties and accolades to improve her standing within the command than she is about being kind and doing the right thing.

I can still remember her venting when a newly-reporting lieutenant had asked if she could leave early. "She left early on Tuesday, and now she wants to leave early today!"

I reminded her that this lieutenant had only been on island for two months and still had errands and obligations tied to moving. "Cut her some slack," I advised.

She fumed, "When is it going to end?"

In retrospect, I believe she really wanted me to recognize that she was doing hard work, which I did, but I didn't acknowledge it aloud to her. So I failed her. And I have to wonder, at what rank do you need to give up the notion of "atta boys" and kudos? Or is this something we all crave no matter our status?

When you do the right thing for your people---that's when you can persuade those people that the journey with you will be interesting and challenging, that's when you can demonstrate to those people that they will gain much and learn more, that's when you know you are truly a leader...and not just someone out taking a walk.

Use Collaborative Leadership to Go Further

2008-06-24T22:27:00.000-07:00

In “It’s Our Ship,” CAPT Mike Abrashoff describes the element missing from his first book, “It’s Your Ship---Management Techniques from the Best Damn Ship in the Navy,” a bold leadership approach that turned the conventional ideas of stodgy senior Navy leaders on its head. I used many of the techniques he described in his initial book to shape my own work environment in healthcare. What he describes in his latest book, and what I have come to realize in my own endeavors, is the wisdom of collaboration.

Instead of encouraging healthy sustainable improvements, competition (as in “the best”) can actually provoke schadenfreude (glee in another’s downfall) and off-track searches for armor chinks. Collaborative leadership looks to the bigger picture, to the mission and accomplishments of the larger organization that create opportunities for all to benefit.

Abrashoff uses the nautical theme to organize his material into eight chapters:

Ahoy – Welcome aboard our ship.
In this chapter, Abrashoff describes one of the techniques he used on the USS Benfold to welcome new sailors and describes learning good and poor leadership in his experiences on the Benfold. He highlights the practices of developing a company “World Tour,” where new employees receive a “passport” with lists of to-do training and customer-service classes. Another company hired its best customers, resulting in a turnover rate of less than 10% while competitors routinely face 70% turnover rates. Companies must continue to recruit people even after they’re onboard.

Buoy up your people – inspiring everyone to be their best.
In this chapter, he states, “A great leader defines excellence and then inspires his team to exceed it through training and staff development.” He then reviews several companies who have developed innovative training programs.

No more aye-aye men (or women) – cultivating truth-telling.
Wishful thinking is dangerous and he gives suggestions on how to deliver bad news and how to keep communication flowing up and down. Honesty and integrity are to be nurtured and encouraged.

All hands on deck – unifying a crew.
Abrashoff says, “Mindless rivalry leads to backstabbing, an ethos of every man for himself, and probably unit failure when danger threatens.” He adds, “Nothing beats the power of unifying disparate people, of showing them the magic of working with and for each other instead of against each other. Quite simply, the first law of leadership in today’s world is to give people irresistible incentives to collaborate for a purpose that enhances everyone.”

Foul weather doesn’t respect rank – creating a climate of trust.
An ancient proverb says a fish rots from the head down. Abrashoff discusses the importance of developing trust, pursuing excellence without arrogance, and treating all with courtesy and respect. He also reviews the principle of fairness and justice.

Navigate by the stars – Clarifying what it’s all about.
Do you know the mission of your organization? Then you have to communicate, focus on what matters, and teach your organization’s core values.

Sail close to the wind – taking the right risks.
Good leaders calculate the odds so risks are minimized.

Fly your true colors – Leading by example and getting results.
Abrashoff discusses the importance of courage. A leader’s main function is to set the right example and leaders can be found at all levels throughout an organization. It’s important to know that good leadership can inspire people to do their best everyday.

In conclusion, collaborative leadership is what makes an organization unbeatable. I highly recommend this book for the interesting situations and the vivid examples leaders at any level can put into play at their companies.

True Leaders Good at Giving Bad News

2008-06-11T01:42:00.000-07:00

The Selection List for Staff Corps Commanders was released two days ago. One of my colleagues was up for promotion and I've talked to her over the past few days. I thought she was holding up remarkably since she was passed over and I'm not sure why I didn't say anything to her about it.

In the passageway this afternoon, the Division Officer for the Emergency Department confided to me that she had told C she was so sorry. C whitened and gave a little gasp. "Is the list out?" she wanted to know.

"You don't know?" the Division Officer asked.

"No," C replied. "I've been checking the message boards constantly." So our esteemed Director for Nursing Services took the cowardly way out of delivering bad news---he let someone else do it inadvertently.

The Division Officer also told me the Director for Nursing Services failed to contact the candidates for the DUINS program (Duty Under Instruction----full-time graduate schooling) who were not selected at this last board. "'I can't get in touch with them," he said,'" she told me. "Well, that's BS because I had no problems contacting them. He just didn't want to be the one telling them the bad news."

Leaders don't get to give only good news. Being able to give bad news and temper it with constructive thought on being competitive the next go-round is a vital communication skill and can make the difference between having a demoralized worker and one energized with a plan for success the next time.

Dr Robert Buckman, an oncologist, knows how difficult it is to deliver bad news. He suggests active listening and kindly communicating reality. When the reality hits, it's important to legitimize the emotions, but not to become emotional yourself.

Perhaps I should be kind and understanding---but I can't. When you wear the rank of CAPTAIN, you lose the privilege to delegate the hard tasks to your subordinates. That's why you're the captain.

Maintaining Clinical Competency Through CEUs

2008-05-25T01:17:00.000-07:00

I talked with a civilian nurse over the weekend who said she had spent nearly $500 to complete enough CEUs to maintain her certifications over the past 2 years. I was flabbergasted. I hope no one else is spending a lot of money to get CEUs when there are so many free options available. Here are some that I use (and I passed this information on to her as well):

http://nursingworld.org/ce/cecatalog.cfm While many require fees, there are two free CEU courses here. Check back periodically for new free courses.

http://www.medscape.com You can establish a homepage based on your specialty; the site requires free registration. It also offers a CE tracker and you can add CE units completed from other sources to maintain an accurate count (great for supplementing your brag sheet when midterms and fitrep periods roll around)

http://www.medpagetoday.com This site also requires free registration and can track CE.

http://www.netce.com/search.php This site has two free courses: Sepsis and HIV. Check back periodically for new free courses.

http://www.jhasin.com/template.cfm?TEMPLATE=include_viewprograms.cfm This site from Johns Hopkins offers a variety of courses. The additional benefit is occasional monograph mailings that enable you to complete CE readings and tests while you're away from a computer.

http://www.mededtoday.com This web site is sponsored by NovoNordisk and has free CEUs for the Registered Nurse and the Nurse Practitioner on a variety of topics.

http://www.cme-today.com This site offers a subscription service for monographs and CEUs. You can also complete CEUs online.

http://www.pcna.net/ This site, sponsored by the Preventive Cardiovascular Nurses Association provides several free CEUs and a host of additional information on cardiovascular health (considering joining!).

http://www.cmezone.com This website offers free CEUs on a variety of topics. Free registration.

Additional CEUs can be found at sponsoring pharmaceutical and hospital equipment sites. They include:
http://www.ahecme.com/
http://www.baxter.com/services/training_and_education/index.html
http://www.cmellc.com/

Make your nursing memberships count. See if free CEUs are offered as part of your membership benefits.

Another option that is becoming available is CE via MP3 or podcast. These allow you to listen through your MP3 player while you do other things.

No one should have to pay for CEU's---unless they want to.

Making Diabetes Self-Management Education (DSME) Classes Fun

2008-02-26T00:24:00.001-08:00

I taught my first DSME class last month. I loved it. Part of being a nurse is being an educator---to patients, families, and colleagues. I hadn't had the opportunity to teach this class before because I had two nurses who were committed to teaching it as their role within a primary care clinic. But one nurse went to Iraq and the other transferred to Washington state. That left me to teach until I can get another cadre of experts trained. I went ahead and joined the American Academy of Diabetes Educators so I can learn and add to my credibility. I don't want to pass the wrong information to these patients who are relying on me.

I am in the process of trying to establish a DSME committee that would have physician oversight with a multi-disciplinary membership. My hope is that the training would continue to be evidence-based and provide a pool of qualified and respected instructors.

A wonderful resource for teaching is found on the University of Michigan web site. While I was waiting for everyone to show for class, I had them fill out this questionnaire on concerns that might interfere with learning about or managing their diabetes. I was amazed at the responses and so gratified that these individuals would trust me with this private information.

One of my colleagues in the Health Promotions Department is more jaded and cynical. I had two no-shows for this class and I contacted them afterwards to discover what barriers or obstacles prevented them from coming. My colleague said, "If you offered bingo along with the class, a $100 pay-out and free cards, you wouldn't have anyone making excuses for not attending. In fact, they would call in sick to work in order to attend!"

I don't want to believe that of my patients. I would prefer to believe that they have other needs more pressing that prevent them from making their healthcare a priority in their lives: grandchildren who must be reared, power bills that must be paid (and no money to pay), fears and worries that so overwhelm them that no action is preferable to making the wrong decision. And so, I am entering this contest to win a book, "The Big Book of Diabetic Desserts, written by Jackie Mills MS, RD. My hope is to have a prize to offer one of my patients. Our Health Promotions Department has funds for purchasing patient education materials, but they cannot fund giveaways or incentives. Consequently, I buy trinkets out of my own pocket. I currently have about 950 Unite for Diabetes pins to distribute to my patients (I started with 1,000 pins). Of course, they're not purchased from the Diabetes web site; I had them made by a Chinese company in Shenzhen, just across from Hong Kong, because a 10-pack of pins cost 30 Euros.

Director for Nursing Services Billet Still Vacant...

2008-02-15T17:33:00.000-08:00

Last week the senior nursing leadership posted an email regarding the selections for Senior Nurse Executive/Director for Nursing Services assignments for Fiscal-Year 2008. Glaringly vacant was the spot for DNS - Naval Hospital Guam.

The spouse envisioned the following dialogue:

Detailer: I have a great duty station for you. How does Guam sound?
Prospective SNE/DNS: Thanks, but I think I'll resign my commission.
Detailer: But you only have 19 years in. You'll lose millions!
Prospective SNE/DNS: Let's see, what is that address again? Oh yeah, jobsearch.com. Be seeing ya.

Recognition Crucial for Recruitment and Retention Efforts

2008-02-15T16:30:00.000-08:00

The department head meeting yesterday was very interesting. Apparently, NO ONE from the command has gotten any formal recognition (NAM, COMM, even LOA) for the part they played in the Frank Cable mass casualty. The Commanding Officer (CO) said, "Well, there were over 200 people at Naval Hospital involved in the incident. We can't give everyone an award."

When one of the department heads said, "Well, the Frank Cable managed to give 113 awards to sailors for THEIR role in the incident," the CO said, "That never happened." Then the Public Affairs Officer cleared his throat and said he could provide the article from the Pacific Navigator.

Rumor has it that the command was submitted for a UNIT award and it was turned down...even though we were lauded throughout the Navy for our medical care.

And they wonder why there is a recruiting and retention problem for Naval Hospital Guam.

In the CO's call yesterday, he showed us two books that were passed out at the Surgeon General's conference: "Made to Stick" and "The Second Rule." I read the first and would like to read the second (I think it's on my wish list….just haven't had justification to pay for it because I have so many other books in the queue). I would recommend the CO read a few other books. My suggestions? "The Carrot Principle," "It's Okay to be the Boss," "It's Your Ship: Management Techniques from the Best Damn Ship in the Navy," and "First, Break all the Rules: What the World's Best Managers Do Differently."

All of these books state definitively that recruitment and retention efforts fail or succeed at the supervisor level and that recognition is what people crave most.

The CO can say, "Naval Hospital Guam gets kudos from all over the Navy," but until he puts his money where his mouth is and we see awards for people other than those who donated "multiple off-duty hours" to coordinating the Navy Ball (give me a break), he has no credibility for me.

Managing by Carrots--Are You Doing It Right?

2008-01-12T21:12:00.000-08:00

Recognizing and rewarding employees is an integral function of the leader and manager. As someone who is internally motivated, I overlooked opportunities to recognize others in the past, but the article below, reprinted with permission from Adrian Gostick and Potentials Magazine, made me rethink the purpose of recognition and how to do it right.

Several years ago, I completed a nomination for one of my colleagues for her volunteer services within the community. When I submitted the nomination up the chain-of-command, the Director looked up at me from behind her desk and said, "Thanks. I meant to do this but ran out of time." The problem is I was a lieutenant taking the time to recognize the activities of a fellow lieutenant and the director was a captain, our immediate supervisor.

If you are truly taking care of your people, how can you possibly run out of time to recognize their good works?

The only praise that doesn't work is the hollow praise of "Good job." It doesn't take much to personalize it and to let the recipient know exactly what the "good job" constitutes. The phrase that pays says, "No one cares how much you know until they know how much you care."

POINTED PRAISE PRODUCES BETTER RESULTS
Recognition without specifics can be worse than no recognition at all
Adrian Gostick and Chester Elton

The next time your young child, grandchild or niece brings home a Rorschach painting from school, try an experiment. Instead of patting her on the head and saying, “Aren’t you just the best little artist,” try talking about the specifics of the painting.

“Why did you use red here?” “What have you drawn here?” “What action is going on in this area?”

When you praise the child and hang the painting on the refrigerator, use specifics such as, “I love how your flowers are turning toward the sun; that’s very observant.” Or, “You know, I don’t know that I’ve ever seen scarier blue alien bugs.” We guarantee that your little one will light up to such specific praise and remember it for a much longer time.

Author and scholar David Cherrington gives a fun demonstration of why such specificity is so important in his book, Rearing Responsible Children.” Cherrington says of one father he observed, “He expressed appreciation to each of his three children individually in the presence of his wife. The father’s comment was a simple statement: ‘I just want you to know how much I appreciate everything you do.’ (The father supposed, like many managers, that any kind of praise would have a positive impact.)

“After he made the comment and left, his wife asked each child why the father had expressed appreciation. The 10-year-old replied, ‘I guess he must be upset because I didn’t get the dishes done like I was supposed to.’ The 13-year-old replied, ‘I don’t know. I guess he was just feeling sentimental.’ The 15-year-old said, ‘Who knows what he meant. I don’t think he understands what’s going on around here.’”

Say what you mean
In the work world, we’ve all known bosses who have fired out glibly, “Hey buddy, you’re doing a great job,” or “I appreciate all you do,” or “You sure look busy.” Unfortunately, these hollow phrases often leave employees wondering, “Does this guy have any idea what I really do around here?”

“Expressing appreciation in general, unspecified terms fails to communicate what the person did right and often appears insincere,” says Cherrington. Instead, when giving praise, describe the great behavior, why it was helpful, and say thanks. It’s that easy.

By taking a few minutes to prepare, and by using a few helpful techniques, your day-to-day recognition moments (and your formal recognition events) can do much more than simply thank employees for their contributions; they can enhance working relationships and increase feelings of loyalty and commitment.

No secret intelligence
To ensure that you’ve remembered everything, consider using the following mnemonic device: CIA – the Company (and department), the Individual and the Award. To help recall this acronym, remember that a good presentation takes a little bit of investigative work.

Company: Be prepared to talk about the company and team goals. You’ll want to reiterate why this is a great place to work (your success, your history, exciting changes, superior quality, etc.).
At FedEx, for example, managers use the recognition presentation as a time to talk about their values of people, service and profit.

Individual: Relate specifically what the individual did to earn this award or recognition and how this achievement helps fulfill your team and company goals. To get the most impact, except with very shy recipients, you’ll want to invite co-workers to talk about the person’s qualities, creativity, dedication and specific work achievements.

Award: Finally, talk about what you are presenting to your employee – whether a formal award for service or performance or a more informal award. If it’s a formal award, talk about the symbolism incorporated into the item – the gold company logo or emblem, the engraving, etc.

Never bad timing
The great thing about carrots is that they are always in season. When times are good in your company, effective presentations will give you a chance to celebrate and reflect. Unlike monetary rewards that dry up when times are tight, carrots can be used during downturns to bring you closer together and give you hope that better times lie ahead.

By making the presentations public, you not only make the person being recognized feel appreciated, but also inspire those who are in attendance. In fact, a great presentation should get people asking themselves, “What memorable or noteworthy things have I done for the company?”

Here’s an example of how it’s done right: Grocery store chain Festival Foods in Onalaska, WI, invites customers and employees to “huddle up” for recognition moments. Twice a year, the company brings in all store directors for hands-on training and meetings called “Festival College.”

After the training, leaders from the company offices go to stores for regular presentations – not only to ensure that recognition is being done right, but to get involved themselves and lead by example. As Festival Foods President Dave Skogen says, “While it’s crucial to have the best quality products and the cleanest, most attractive facility, ultimately it’s employee attitude that brings customers back.”

Adrian Gostick is director of marketing and corporate communications for the O.C. Tanner Recognition Company (www.octanner.com). Chester Elton is national director of performance sales for O.C. Tanner. This article was excerpted from their book The 24-Carrot Manager: A remarkable story of how a leader can unleash human potential (Gibbs Smith, 2002).

If you don't have time to read, consider listening to their podcasts:
http://www.podcastdirectory.com/podcasts/6582

Are You a Knowledge Hoarder?

2008-01-08T20:36:00.000-08:00

In my previous incarnation as a small unit leader, I was not wildly successful. It stemmed largely from my personal insecurities. When I needed someone to cover for me or to complete a project, I was helpful...but not as helpful as I could have been. I invariably omitted some vital piece or a bit of information that could have helped the other person succeed. I called this "knowledge hoarding" and I was a consummate player in the game. It took me a long time to realize that true power comes from knowledge sharing.

As a more seasoned leader, I try to give my juniors all the information I can. The benefit of open communication means they come to me with their questions and concerns, and they often possess information I need to provide to senior leadership.

Marshall Goldsmith addresses this issue much more eloquently than I can, and he and Patricia Wheeler have graciously permitted reprinting an excerpt from one of his monthly newsletters here. Consider subscribing to Leading News---their monthly newsletter dedicated to helping leaders become successful.

Withholding Information
By Marshall Goldsmith

In the age of knowledge workers, the saying that information is power is truer than ever—which makes withholding information even more extreme and irritating.

Intentionally withholding information is the opposite of adding value. We are deleting value. Yet it has the same purpose: to gain power. It’s the same old need to win, only more devious. And it appears in more forms than merely playing our cards close to our vest. You see it in people who exaggerate the virtue of keeping a secret; they use it as an excuse to leave you out of the information flow. You see it in its passive-aggressive incarnation in people who don’t return your phone calls, answer your emails, or only give partial answers.

If you don’t understand why it annoys people, reflect on how you felt about the following events:
- A meeting you weren’t told about
- A memo or e-mail you weren’t copied on
- A moment when you were the last person to learn something

The problem with not sharing information—for whatever reason—is that it rarely achieves the desired effect. You may think you’re gaining an edge and consolidating power, but you’re actually breeding mistrust. In order to have power, you need to inspire loyalty rather than fear and suspicion.

What I’m describing here is not just the willful poison-sowing refusal to share information, the way people behave when they want to divide and conquer. I’m also talking about all the unintentional or accidental ways we withhold information.

We do this when we’re too busy to get back to someone with valuable information.

We do this when we forget to include someone in our discussions or meetings.

We do this when we delegate a task to our subordinates but don’t take the time to show them exactly how we want the task done.

I was advising a friend who was having trouble with his assistant. They weren’t meshing as a team but he didn’t know why or how to fix the problem. I asked him, “What would your assistant say is your biggest flaw as a boss?”

“That I don’t communicate enough with her,” he answered, “and I leave her out of the loop.”

I observed him one day at work, and what I saw explained everything. He was already at his desk checking his e-mail when his assistant arrived. She poked her head in to say good morning, and he waved as he talked on his cell phone. When the call ended, he turned back to his computer. His assistant periodically came in to notify him of calls, which he took while continuing to scan his computer. After a few hours, I asked him if all days were like this.

“Pretty much,” he said.

My friend, indeed, was guilty of keeping his assistant in the dark, but he was not doing so maliciously or intentionally. His work life was like a haphazard fire drill. He was so distracted, so disorganized, so busy responding to calls and putting out fires that he never had time to sit down with his assistant for a daily briefing.

If he had, I suspect it would have solved their information sharing issue.

I suspect this is a big reason why so many of us withhold information. It’s not that we want to keep people in the dark. It’s simply that we’re too busy. We mean well. We have good intentions. But we fail to get around to it. As a result we become bad at sharing information, and over time it begins to look like we are withholding information.

Being bad at sharing information doesn’t mean we are willfully withholding it…but the net result is the same in the eyes of the people around us.

How do you stop withholding information?

Simple answer: Start sharing it.

That’s what my friend did. He made sharing information a higher priority in his busy day. He made time to debrief his assistant daily, and held to this commitment no matter what was going on.

If this is your problem, I advise the same solution. You will not only improve your communication, but you will prove that you care about your coworkers, demonstrating that what they think matters to you. It’s not often we get such a two-for-the-price-of-one solution to our interpersonal challenges…but making the subtle shift from withholding to sharing information is one of them.

Excerpted from What Got You Here Won’t Get You There, 2007

Marshall Goldsmith is a world authority in helping successful leaders achieve positive, measurable change in behavior: for themselves, their people and their teams. He has been named one of the top 50 leaders influencing the field of management over the last century (American Management Association), one of the five most respected executive coaches (Forbes) and among the top ten executive educators (Wall Street Journal). Marshall invites you to visit his library (MarshallGoldsmithLibrary.com) for articles and resources you can use.

Checklists for Healthcare Providers

2007-12-14T14:52:00.000-08:00

There is no way healthcare providers can rely on their memories to guarantee evidence-based practices. We are too busy, too fragmented, and too hurried.

This article from The New Yorker explains why checklists work:
The Checklist

The biggest push in patient safety today is crew resource management which is based upon standard practices to achieve safety in the aviation industry. I think we will be seeing huge differences in medical/healthcare practices in the future.

Attention to Detail...

2007-12-06T01:02:00.000-08:00

I recently got my birthday card from the Commanding Officer. It was handed to me by one of the corpsmen on my old unit, F-2. I've been off that unit since July. The CO has seen me many times since then and knows my current assignment since I was called in to his office on a patient satisfaction issue a week ago and the appointment was set up weeks prior to that.

My first birthday card from this CO went to the ICU. I cut him some slack because he was relatively new to the command and I figured I was just another face in the crowd. To make a mistake like this a second time, well...I realized it just doesn't mean anything at all. So it went right into the trash.

As a believer in good stewardship and using limited resources wisely, it pained me. Whether the CO actually signed it or not, someone took the time to type out a message on command letterhead (good quality) and he signed it or someone stamped his name. Someone made sure my letter got out of his office. And then they couldn't follow through.

The Business of Being Born

2007-12-01T19:13:00.000-08:00

Celebrity actress/host Ricki Lake's new movie, "The Business of Being Born" points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.

The Next Inconvenient Truth?

"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.

To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.

"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."

A Movement Underway?

Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.

Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:

"It's obvious," he says, "that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here and the ten o'clock at night is, 'I don't want to be up all night.'"

FAST FACTS:
-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"

-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.

-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.

-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.

Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."

She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."

Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."

I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.

Addendum
ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone

Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:
http://www.mcfarlandpub.com/book-2.php?id=978-0-7864-3362-9

Relationships Critical in Effective Leading

2007-10-19T21:11:00.000-07:00

This month's issue of Center for Creative Leadership says "the ability to build and maintain relationships and work well with others is in big demand - and in short supply."

While I might think a leader is the one on point setting the pace, it's the manager who collaborates amongst departments to share resources, develop programs, and train personnel while simultaneously integrating direct reports' career and family desires with senior management edicts. So who really adds more value to an organization?

CCL says "Organizations are increasingly operating in ways that involve interdependent, boundary-spanning work - creating a greater demand for leaders who are skilled at participative management, building and mending relationships and change management."

Today's Navy Nurse manager [Division Officer] usually cannot offer choice job assignments although senior management does try to match career desires with billet openings. I have found that giving an expected timeframe for this transfer to a coveted position helps as well as exploiting opportunities for cross-training when workload is light. It also helps that nurse develop relationships with nurses already working in that department so this person is not only getting the benefit of me "pushing" this person to that department, but the department is "pulling" that person to come work with them in staffing meetings.

We cannot pay someone more for working the off-shift, weekend or holiday. This past summer, when staff members were working 18-20 twelve-hour shifts and on-call for more, the Nursing Middle Management Council wanted to reward those staff members with----a pizza party. I rolled my eyes. "Why not reward them with something that REALLY matters?" I asked. "Why not submit a nomination for a Navy Achievement Award---something that would appear on a fitness report and be presented in front of peers by the commanding officer?"

The response? "I'm really busy. I don't have time to write up a nomination." So, calling Pizza Hut or Dominoes is the ineffective leader's gift to direct reports. And it gives me a very good insight as to this manager's relationship abilities.

"Health" Magazine Writer, Suz Redfearn, Advocates Deceptive Practices

2007-10-18T15:49:00.000-07:00

The teaser arrived in my email box---Nine Secrets Health Insurers Don’t Want You to Know---and I clicked. Suz Redfearn, a freelance writer, says that

To get tested, talk up your symptoms.Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary. But if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease, here’s how to get one covered: Mention to your doctor that you’ve had some blood in your stool and a lot of gas lately—or simply that your bowel habits have changed.

First, this is obviously not a colonoscopy but a flexible sigmoidoscopy. It costs a lot more for the more extensive procedure that checks the right side of the large bowel in addition to the transvers and descending colon. And sedation typically is not given for the flexible sigmoidoscopy. Most patients do not require colorectal cancer screenings before the age of 50. These exceptions include those with a history of familial adenomatous polyposis, obvious changes in bowel habits (bleeding, changes in diameter of stools, and unexplained anemia), and first-degree relatives diagnosed with colorectal cancer.

The National Cancer Institute has a wonderful site that explains the various options available for colorectal cancer screening. I would encourage all patients to discuss their risks with their providers and not resort to subterfuge or lying in order to obtain a test that may not be necessary.

I sent a letter to Health stating my disappointment with their decision to publish an article that advocates lying and deception in the patient-provider relationship. Healthcare providers already manage patients who claim they take all their medications as prescribed, who exercise as recommended, and who avoid dangerous health practices. Let's add another nail of skepticism to the communication coffin.

Other blogs about this article include:
California Medicine Man
Kevin MD Medical Blog

October is National Breast Cancer Awareness Month

2007-10-07T23:13:00.000-07:00

In the summer of 1994, our neighbor wore a turban and we learned she had breast cancer. I remember being invited over to their apartment with walls lined with books from floor to ceiling. She and her husband had three children who were crammed into this little apartment.

One day we came home to find her crying in the hallway. "Are you okay?" we asked, concerned. She shook her head no. "It's in my bones," she said.

I've thought about her off and on over the years. The five-year survival rate for breast cancer with metastasis to the bones is 21%. I hope she is still alive; her husband and children deserve that much.

Breast cancer is the leading cause of death in women ages 20-59 while lung cancer is the leading cause of death in women ages 60 and older. Breast cancer diagnosed in the early stage, that is, while it is still localized to the breast has a 96% chance of survival. This is why mammography is so important. There are no early signs or symptoms of breast cancer; even the monthly breast self-exam (BSE) detects cancers at much later stages than radiology.

My annual mammogram is scheduled for this month and I am not looking forward to it. However, the inconvenience and pain of being diagnosed with breast cancer far outweighs the inconvenience and pain of this diagnostic exam.

For more information, please check http://www.nationalbreastcancer.org/

Too Sick to Take Meds

2007-10-04T05:06:00.000-07:00

From the Chicago Tribune:

"In a new study published Thursday, a group of University of Chicago doctors found many diabetics believe that the inconvenience and discomfort of their treatments, especially multiple daily insulin injections, were as bad as the complications that can result from not treating their disease.

"Some patients, 10 percent to 18 percent of the total, said their treatments were so arduous that they would be willing to die sooner -- some said up to 10 years earlier -- if they could stop their medications.

""Some of this might be lack of education and people not understanding the disease process," said Dr. Holly Mattix-Kramer, a specialist in preventive medicine and kidney disease at Loyola University Chicago Stritch School of Medicine. "We need to do a better job educating our patients about what preventive care means and how it may affect their life span.""

I wonder if the providers evaluated these patients for depression.

There is a lot of support given to patients who are diagnosed with cancer. We have cancer support groups, we hold fund-raisers, and we generally don't fault these people for getting cancer (well, maybe we think smokers have it coming....).

In any case, there is no support for diabetics. Many diabetics have made lifestyle choices that have predisposed them to diabetes and, for some, lifestyle choices may have delayed but did not prevent the onset of diabetes. So others look at these people and "should" all over them. "You should have watched your diet. You should have lost weight. You should have..."

You cannot be dumb when you have a chronic illness. You have to track all sorts of medications, the timing, the changes in your diet and lifestyle (to include exercise and stress management as well as checking your feet every night) and then tweak your dosages when the next evidence-based practices are published. This means multiple visits to your provider and pharmacy and maybe visits to the emergency department when you take too much or too little of a medication. Think about all the time spent on managing this illness...

A multitude of factors comes into play here---psychological costs as well as very real physical costs. My only hope, as an adult nurse practitioner and clinical nurse specialist in adult health, is that these patients make INFORMED decisions---that is, they understand the full ramifications of the radical steps they are about to make and understand they may not be able to change their minds once they start down that path.

If they are honestly able to make this decision (and not just overwhelmed with the sheer agony of it all), then we as fellow humans have an obligation to support them in their decision and to allow them to die with dignity and grace.

New Assignment

2007-08-08T22:51:00.000-07:00

I've been in the General Surgery Clinic for a month now (no more Dead End Corridor!). Life here is certainly different from life on the Multi-Service Unit. For one thing, I don't supervise any nurses and I have a capable and confident HM3 who manages the clinic itself and trains new corpsmen.

My main role here is to assist with endoscopic procedures through administration of intravenous conscious sedation (IVCS). I thought this would get boring, but I've been pretty interested in all the cases we've done so far (57 cases, if you include the 6 in which I was supervised to re-certify for IVCS and the 6 I supervised another nurse to get her IVCS-certified).

Today we saw worms.

Dr C got the willies. "I can't wash my hands enough after this," he declared. He kept muttering, "Wait till my friends see this on You-Tube." Then he'd shiver some more.

Medical Mistakes Happen

2007-07-27T14:40:00.000-07:00

This newspaper in Wisconsin details some of the medical mistakes healthcare providers make. Here is another link to a web site for journalists covering healthcare: http://www.healthjournalism.org/

I regularly receive the ISMP newsletter (offers free CEUs twice a year!) and have been amazed at some of the errors RNs have made. As nurses, we are instructed to use the "6 rights" of medication administration:

Right patient

Right medication

Right dose

Right route

Right time

Right indication

However, using these 6 rights does not guarantee patient safety. Critical thinking skills are essential and even then they can fail the best nurse, especially in Hour 10 or 11 of a 12-hour shift on the third day of a string of 12-hour shifts.

Patients must take responsibility and ask questions about the medications that are being administered to them. I frequently encounter patients who have no idea what medications they are taking or what they're used for.

Here is a link to an online medication form that patients can use to fill out and carry with them at all times. The Institute for Healthcare Improvement (IHI) provides extensive information from hospitals nationwide who have implemented safer healthcare delivery practices. The site requires free registration to access information and I have found it to be a wonderful resource.

As an RN, I tell my patients they should always ask who the person is who is administering the medication (are they an RN? a CNA? a crazed patient from room 210 who is offering you his stashed medicines?). Patients should also ask what the medication is, the dosage, and what the medication is used for. The RN should also instruct the patient on the common side effects and what the patient should do if he or she experiences one of them. However, this would happen consistently in the ideal world and that's not where we live.

Dinosaur Nursing

2007-07-19T22:41:00.000-07:00

We were critically short-staffed before and now one of our nurses left on emergency leave this morning. You can't run a schedule with five nurses. In the meantime, I've been moved out of the MSU to General Surgery. They chose another nurse to cover both her clinic and the MSU which doesn't make sense. I still had to manage a physical readiness issue for one of the sailors and I am writing three end-of-tour awards for staff detaching in the next couple of months. I also have to turn over with the Division Officer who will be taking my place.

The other nurse covering the ward chose to have nurses work 8-hour shifts in addition to their regularly scheduled 12-hour shifts so a new graduate nurse was not left on his own on the night shift. I argued that the 8-hour shifts would actually be longer because things happen and staff would be reluctant to leave, even when their shift was over. She responded, "When I was a nurse at their level of experience, I had to work seven shifts to get four off!"

I replied, "Dinosaur nursing doesn't work nowadays."

She retorted, "These nurses are just BABIES! They need to suck it up."

Quietly, I said, "These nurses are not babies. They are adults who have different priorities." But she had already turned and walked away.

It's times like this that I have to apply the 5-year rule: Will this really matter in 5 years? And my response is no. And I am sick and tired of the phrase, "Suck it up."

Slow Leadership says this:

"...organizations rely on people's feelings of loyalty. Not loyalty to the business, mostly, but loyalty to colleagues, who will be forced to take up any slack if someone refuses to give up vacation time or work a 60 or 70-hour week." The best workers vote with their feet: "Those with the most courage, the highest levels of self-confidence, the greatest commitment to ethical principles, and the strongest personal values leave."

Slow Leadership continues: "One of the differences between high levels of stress and actual burnout is the presence of depression. Someone suffering burnout has given up. He or she no longer has the power to fight, nor the self-esteem to put the blame on the organization, where it belongs. The burnout victim was, typically, an ambitious high-flier, a good team player who gave and gave until
there was nothing left to give."
Finally, Slow Leadership says, "Work is part of life, not the other way around."

What I should have asked this senior nurse is, "Don't you remember how angry, how powerless you felt when you were given these demands? Didn't you vow then to never become that kind of nurse or leader?"

Managing Across the Generations

2007-07-12T02:45:00.000-07:00

One of the blogs I frequently read is Penelope Trunk. She posted a report published by Deloitte & Touche on managing across the generations. You can download the report here:
http://blog.penelopetrunk.com/wp-content/uploads/2007/07/deloitte-generations.pdf

I also recently read a report in Training Magazine that despite beliefs generational differences exist, all generations share core values which include an emphasis on family.

My husband has told me I can "stay Navy" or I can stay married. The biggest change in regarding the Navy as employer of choice is the massive number of hours I work at the expense of time with my family. At this point, I am working over 50 hours a week. There have been times in the past few months where I have worked six 12-hour shifts in the space of seven days. Unfortunately, I am not the only one in this situation. This will have increasingly chilling aspects for Navy recruiting as it attempts to do more with less.

My Learning Edge

2007-06-28T16:47:00.000-07:00

Adam Kayce of "Monk at Work" has challenged me to push the envelope of my intellectual horizons...which I believe I do on a daily basis in my commitment to lifelong learning.

I just finished reading "It's Okay to be the Boss," by Bruce Tulgan of Rainmaker Thinking. I was a hands-off leader, which is great if you're leading Marines, but it wasn't the appropriate leadership or management style for the nursing unit I was assigned. It only took me 15 months to realize I needed to be more hands-on, more involved, and more directional.

When one of my staff members died at his own hand last year, I realized I didn't know as much about him as I wanted and now it was too late. I was very blessed to have had the conversations that I did with him, but I didn't ask the difficult or probing questions that might have given me more insight, might have made me more empathetic, might have given me more forgiveness. I vowed never to let that happen again. So I gave index cards to my staff members and asked them to write the names and addresses of someone who would care to hear news about them. I asked for their birth dates, their anniversaries, and the names of any children, their ages. I wish I could say I developed this myself, but Michael Abrashoff of "It's Your Ship: Management Techniques from the Best Damn Ship in the Navy," gave me the idea.

So far, I have written 15 cards to parents and friends discussing one or two qualities I admire in their loved ones, how happy I am to have them working on my unit and what they are doing or learning, and how much promise they show. My staff members are, for the most part, under the age of 24, away from home for the first time and half a world away. It costs at least $1800 to fly home and it cannot be accomplished over a long weekend. They are also in a profession where they can be called as an individual augmentee to any humanitarian or wartime mission.

It has taken being a mother and losing a shipmate to improve this particular leadership element in myself, pretty steep tuition at the School of Heartbreak and Brutal Experience.

Individual staff members have spoken to me over the past few weeks saying how much their family appreciated hearing about them. One staff member did not know that his family had received my card until he saw it posted on the refrigerator while home on leave. They didn't throw it away. That means a lot to me.

Anything in the Nut Family

2007-06-23T23:54:00.000-07:00

The ICU transferred a patient to us. Admitting diagnosis was "1. Salicylate Overdose, resolved. 2. Suicide Attempt 3. Depression."

In response to questions regarding allergies on her nursing assessment database, she wrote, "Anything in the nut family."

Pathological Rib Fracture

2007-06-10T04:37:00.000-07:00

A 77 year old male with no relevant past medical history checked in with back pain. Films showed an abdominal aortic aneurysm and a pathological rib fracture. On incidental findings, the patient also had a pathological hip fracture.

He had a mass in the left lower quadrant that I was quite able to palpate, although I was unable to appreciate the AAA (which, according to assessments, was a "pulsatile midline abdominal mass").

He is a full code---he and his family couldn't wrap their brains around the fact that if he were to code, we wouldn't be able to save him. We would break all his ribs and probably rupture his abdominal aorta, causing certain death.

I think the thing that made me saddest was what Dr J said when I called to get an order for Zofran. "Thanks for taking such good care of this patient."

And I wasn't doing anything different I wouldn't do for any other patient.

Sudden insight on a late Friday afternoon

2007-05-05T01:27:00.000-07:00

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."

Escaping the Dead End Corridor

2007-05-05T01:21:00.000-07:00

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.

Mary K & and Terrible, Horrible, No Good, Very Bad Day

2007-05-05T01:17:00.000-07:00

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.

Disruptive Physician Behaviors

2007-05-05T01:07:00.000-07:00

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.”