Monthly Archives: February 2012

nurses can learn from Harry Potter. What you didn’t learn about pharmacology in nursing school

you are invited to subscribe to this blog, and share with friends (see buttons at side and bottom). And while you are at it, buy my book about the first time I worked as a nurse in Nepal, a low-income country in Asia. It may not help you pass NCLEX, but maybe it will remind you why we all do this…..  and by the way, be sure to check out the hyperlinks…..

“Thank God I finally passed NCLEX. Now I don’t need to study any more!”

Every time a recent grad calls or emails to share their happiness at passing NCLEX,  my reply is the same. “Congratulations. Now the real learning begins and it is a lot harder than what you learned so far.”

Okay, I have never seen a prescription for gillyweed in a hospital

But gillyweed might have some medical applications….

What you learned about pharmacology

today’s blog will be short and to the point. What you learned in nursing school was about drug action, typical dose, side effects, nursing implications, and the Five Rights. Most pharmacology courses are a survey of drug categories, an inventory of all the possible drugs, some of which are very interesting and intricate but which are also specialized and you may never administer in real life. Pharm is generally taught as one of the “hard sciences,” often by a pharmacist who may not necessarily have done much clinical pharmacology.

The faculty job

You can do the Five Rights and still not exhibit the best judgment, giving a drug that ought to be clarified with the doctor or pharmacist based on something you found during the physical exam.  The job of the faculty is to make sure you consider all these things before you give a drug. As you might expect, a student never ever gives a medication, not even an aspirin, without a faculty person present.

What you learn in real life

The trends include learning not just about meds (the most important category of medical errors) but medication systems, and also studying errors made by others. For example, we all know what potassium is and what it does; but do they teach you why we never keep vials of it on the nursing wards? or why hemocult developer is never kept in the med drawer?

We all need to become systems thinkers – Like at Hogwart’s School!

People sometimes call me a pessimist because I sometimes share stories about  bad things we want to avoid. Most of the time, we want to focus on what to do, as opposed to what not to do….. if you dwell on the negative case all the time, the theory goes, students gets confused and will not develop confidence. Finding a balance between these things is part and parcel of developing the judgment expected of a skilled professional person.  We need a healthy respect for the side effects and adverse effects of medications, and for that reason I share war stories.

One of the brilliant things about the Harry Potter books is that JK Rowling included something like this in the Hogwarts curriculum – Harry Potter and company spent time  “studying the defense against the Dark Arts…”)  meaning that they had to learn about all the possible bad things that might happen. (to them). Of course, this makes for a very engrossing plot. (being a teenaged muggle is bad enough without the extra element….) Frankly, when most pharmacology courses just cover drug action and pharmacokinetics, there is not enough space and time in the course to spend as much time studying systems in any detail…. I think more attention needs to be devoted to this, all along the way.

Two things every student and new nurse  can do.

First, go to the Joint Commission website and read about error prevention and sentinel events. The Joint Commission publishes free podcasts and email newsletters. plan to subscribe. They are up to issue #47 lately – read the back issues.

second, subscribe to the FREE NEWSLETTER from the Institute for Safe Medication Practices.

 

 

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part 2: The Nurses “Brain” – how to bring your “A Game” to clinical

read part one first. That was among my most popular entries ever. If you are finding this useful, your fellow students probably will too – why not share it with them? It’s part of a series of blogs on the current nursing scene, especially for new nurses and nursing students. I also invite you to  subscribe!

“What we Have here, is a failure to communicate…..”

There are a few common scenarios in nursing education. These take place at clinical.

a) at the end of the clinical day the instructor is making rounds after the students have left, and one staff nurse says “your student in rm 438 did not give a bath, did not report the vital signs, and omitted a med that was due at noon” (this always puts the faculty on the defensive, in case you wanna know)

b) the teacher and the student are lined up at the med cart about to give a heart pill, and the student did not check the Apical Pulse or take the Blood Pressure. Or maybe it’s a stool softener and the student has no idea when the last time the patient moved their bowels. or maybe it’s lasix and the student doesn’t know what the K+ was.

c) the student takes report from the night nurse, but doesn’t write anything down and can’t recall what was said when the faculty asks what the night nurse had to say about the patient.

I can think of more; but what I want you to ask yourself right now is, have any of them happened to you?

The reaction to all of the above, is to pass the feedback along to the student, and maybe to put the student on a written warning, which is logical. After all, we’re about doing our best, here. If the student gets enough written warnings, they learn to be afraid of making a mistake, (which is good); but they also learn to dislike clinical, (which is bad. clinical is the reason we are here). And the faculty wonders why this happens over and over again…….  a new faculty person is also on a learning curve, and when you are new at teaching, y0u may not have the tools to develop a better approach. It’s easy to blame the students….

Pro-Active? or Re-Active?

Simply dumping on the student is usually a sign of a faculty member who did not see the value of teaching organizational skills to their crew. It’s the easy way out – a way for the faculty to shift blame. It’s Re-active – closing the barn door after the horse has left. Both the student and the faculty will benefit from a pro-active approach – oh, and so will the patient :-)

You may find this difficult to believe, but to use a Road Map, also known as the Nurses Brain, is a pro-active tool in preventing all of these things from occurring. There is no situation so chaotic that a Brain can’t bring some order when it is applied.

Part One dealt with how to set up a Brain.

I got a terrific reply to Part One  from Dan Keller, a nurse who has a Blog Site Titled Nurses Get it Done. Dan was very humble about his site, but I was happy to find it. Go there, and you can find more examples of a Nurse’s Brain. He also has info about an iPhone app that can be used to keep track of all the little pile of details that a nurse has to deal with.

So – how to become pro-active vs Re-active?

For me as a faculty, I require that the student bring a Road Map to clinical and show it at the beginning of the clinical day. Every time I speak with that student during the day, we pull it out and go over it. Every time a staff nurse gives report, the student also writes down every tidbit of data that has been shared, and the student has to determine whether a followup response is required.

I got another email from a nurse who said she wants to make sure the student can name what’s going on with their patient “and that’s the most important.”  Fair enough. She probably works with seniors; and also,  when you make a Road Map every day, you can add reminders to yourself to schedule an actual time to physically assess the most important feautures of your patient’s illness event. In addition to the Road Map, we also require a Concept Map, an eight-column medication form etc – if I made it sound like we didn’t, or that I never bring up the more sophisticated concepts of patho, don’t worry – we do those things.  The time to start using a Brain is Fundamentals – from the beginning of hospital practice.

Accountability

One of the mantras is: ” we don’t have to do every single thing we planned out for the Road Map, but if we can’t, our responsibility is to tell the staff nurse with sufficient time so that they can do it before it’s too late”

If the whole crew is using a road map, it allows the clinical groups to create synergy, and help each other by scheduling some tasks for the larger group – such as doing incontinence care for a 400-lb helpless patient, for example, which would require more than just one person. I worked at a 400-bed hospital in Bangor, Maine, where the nursing crew routinely delivered care for  patients with life-threatening morbid obesity – that group of nurses were a marvel of teamwork. This eliminates a lot of mini-crisis from the day.

Buying the morning paper?

The next thing that can happen with a well-planned Road Map is effective chaining of tasks. Now, women are much better at chaining tasks than guys are ( hate to sound sexist and I don’t know why this is the case, but I think it’s true). True story: if I was going to get the morning paper from the corner store, I would go and get it. But, if I mentioned to  my wife I was going down the street for that purpose,  she would say “Oh, and we also need toilet paper and would you get some bread and milk too?”  My wife was also a nurse. Nurses become excellent at “chaining” tasks.

Chaining….

an example of chaining for the Road Map would take place after you observed that it was an hour after breakfast and  your patient was incontinent of stool.  Obviously, you are going to help them with personal hygiene; so you might as well do their whole bath at that time, and you will bring in the supplies to do a sacral dressing change if they have a sacral wound, and you can also check their heels at the same time, do range-of-motion and repositionthem. six tasks with just one trip into the room.

The Checklist Manifesto

We are on a quest for excellence in nursing, not just personal excellence but excellent patient outcomes in team care. And I can’t speak highly enough of the books by Atul Gawande, MD.   His book, the Checklist Manifesto, is about the ways that teams improve, and he has lots of practical examples and a great way to express how to approach the idea of improving your practice day-to-day.

I can’t really add much beyond what the reviews have already said, but here is a start, from Amazon.

Amazon Exclusive: Malcolm Gladwell Reviews The Checklist Manifesto
Malcolm Gladwell was named one of TIME magazine’s 100 Most Influential People of 2005. He is most recently the author of What the Dog Saw (a collection of his writing from The New Yorker) as well as the New York Times bestsellers Outliers, The Tipping Point, and Blink. Read his exclusive Amazon guest review of The Checklist Manifesto:

Over the past decade, through his writing in The New Yorker magazine and his books Complications and Better, Atul Gawande has made a name for himself as a writer of exquisitely crafted meditations on the problems and challenges of modern medicine. His latest book, The Checklist Manifesto, begins on familiar ground, with his experiences as a surgeon. But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world–and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking.

Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

The danger, in a review as short as this, is that it makes Gawande’s book seem narrow in focus or prosaic in its conclusions. It is neither. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help. –Malcolm Gladwell

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part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere!

Shhhhhhh…..

I don’t normally share the deepest secrets of my trade with just anybody.

But you?  you are special!

pull up a chair and listen closely….. I will reveal to you a mystery of life which will change your destiny….. if you can handle it….. after this your nursing school trajectory will be brighter and happier….. and while you are at it, subscribe to this blog. At the bottom, you can click on a “Share” button to help your friends. Don’t you want them to do well too?

9781632100085-SOTG-Nepalt.indd

The back cover of my book. If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at https://goo.gl/PGTW30

 

 

Oh, and buy my book. It’s a novel I wrote to convey what it is like to work overseas in a missionary hospital. It’s not a sugarcoated version – the medical details are extremely accurate and well researched. It’s not the usual textbook but some schools have added it to the Global Health reading list. There is a love story of course!

Skills are more than psychomotor by nature

Okay, so I teach beginner nurses how to be a nurse. We start with well-meaning intelligent kids and turn them into professional persons. When people think about the skills nurses need to have, they list things such as giving a shot or doing a dressing change.  Using sterile technique and doing the Five Rights of medication administration.  Close your eyes and picture a nurse at work, and this is the image that comes to mind. These are the psychomotor skills, hands-on things we do for people.

It’s just as important to learn how to juggle time, set priorities and estimate workload, but these are “soft skills” – and a behavioral scientist might argue that since these can’t be demonstrated, they do not exist….. now – an educational paradox exists.

The Road Map to Success

The key to learning these skills is to learn how to use a Nurse’s Brain, what I also call a road map, and to incorporate it into your daily life.  If you are not now doing this, it will be the biggest single revelation of your trip through nursing school.

Simplest version of instructions

This is part of teaching a new nurse how to prepare. Depending on your curriculum, the faculty will tell you ” go to the hospital the day before and learn about your patient.” A less experienced faculty member might leave it at that, and set you loose. Nobody tells you how much is “enough,” but a less experienced faculty will reserve the right to criticize you when you didn’t do it right.

Long ago I learned that beginners need to be shown how to prepare and given a specific description of what this entails. Effective prep is a skill in and of itself.  Here goes.

Here is how to prepare

You will read the chart for all kinds of things – the diagnosis, allergies, meds, etc.  your school will give you a template as to things you are looking for. look up each med the person is receiving. that sort of thing.

BUT, in addition to this – when you read the chart, you find the specific list of interventions and activities for the day. they will be always be somewhere, in the old days it would be found in the “Kardex”.

Six Steps to actualize it into reality and answer the question “what do nurses do all day?”

1) Start with the “Doctor’s Orders” (which aren’t really “orders,” we just call them that…we carry them out but that is not done blindly) a typical list goes like this:

allergies: none known

diet: NPO

v.s. q 4 h

activity OOB to chair TID

midline w > d dressing to abdominal wound q 8 h

I & O

foley catheter to bedside drainage

veno-dyne boots to LEs while in bed

pain med PRN

IV D 5 NS at 125/hr

that sort of thing. okay, this was simple enough. your job is to make it happen

2) The next step is to assign a specific time to each activity. so you make a piece of paper that looks like this:

0700

0730

0800

0830

0900

0930

10 00

1030

1100

1130

you can make a template for this, and there are lots of examples of sample Brains out there….

3) next, take all the items on the first list, and add them to the second:

0700 – nurses report, find out who the nurse is.

0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter

0800 – mouth care ( since he is NPO),

0830

0900 – ask about pain med again,

0930 -dressing change

10 00 – get OOB to chair, check I & O,

1030

1100

1130 – take vital signs again (it’s four hours since the ones you took this morning)

4) next, go through the list again, and add stuff that is assumed to be needed, according to the routine of the unit

0700 – attend nurses report, find name of staff nurse also covering your patient

0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter

0800 -look at IV site q 1 h

0830 – bathe patient

0900 – ask about pain med again, -look at IV site q 1 h, give 0900 meds if any

0930 -dressing change, ask about pain if the patient got some med in advance

10 00 – get OOB to chair, check I & O, -look at IV site q 1 h

1030

1100 – write DAR note in patient chart, complete ADL checklist

1130 – take vital signs again (it’s four hours since the ones you took this morning), report off to staff nurse

0700 – attend nurses report, find name of staff nurse also covering your patient

 5) next, add some details that might not be obvious. put a box next to each item so that you can check it off when it is done.

0700 – attend nurses report  ___,

find name of staff nurse also covering your patient ___________

read specific instructions for dressing change and check to see if supplies are in the room _____________

0730 – take vital signs, ______________

and report to staff nurse,____________

ask about pain,______________

assess dressing, _____________

check venodyne boots _________________

and IV site, ______________

look at catheter, ______________

check sacrum and heels,____________

reposition if needed,___________

listen to Bowel sounds____________

and lungs______________.

confirm that ID band is in place________________ (so you will save time later when giving meds).

check call bell and make sure patient knows where it is ___________

0800 -look at IV site q 1 h ______

assess mouth and do oral care ________________

see if any other students need help with turning their patient or incontinence care _____________

doctor’s rounds _____________

0830 – bathe patient ______,

do cath care ___________

complete head-to-toe assessment sheet from School for care plan.___________

ask patient about discharge plan, _______________

assess need for teaching _____________

leave bed in low position after bath __________

0845 – short coffee break _________

report to nurse that you will be leaving for fifteen minutes _____________

check to see doctor’s orders if any new ones were written ___________ check lab results for today _______________

0900 – ask about pain med again, _________________-

look at IV site q 1 h, _____________

give 0900 meds if any. ____________

make sure you took B/P _________before giving meds. ___________

decide what the theme of the DAR note will be. _________________

0930 -dressing change,____________ (follow recipe)  ask about pain if the patient got some med in advance,

10 00 – get OOB to chair,_______________

check I & O,_____________

-look at IV site q 1 h_____________

1030

1100 – write DAR note in patient chart___________,

complete ADL checklist ___________

1130 – take vital signs again (it’s four hours since the ones you took this morning), ____________________

report off to staff nurse _________________

This is the short version. When I first teach people to do this, they may have up to forty items on the list, because they need reminders of everything.  As you can see, the Brain evolves as you add things to it. doing a dressing is more than just doing the dressing – it’s checking the pain med, checking the order, gathering supplies, and negotiating a time. each of these gets their own spot on the checklist.

If your whole clinical group is using something like this, you can plan your work as a team; you can make time to help others; and you learn to share a language as to when each team member needs help or not.

6) During the time at clinical:

http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/the Nurses Brain goes on a clipboard, and you refer to it every fifteen minutes. cross off each item as you do it. at 0900, every item that was assigned a time before 0855 ought to be done. If not, you now know which are the priority items. when something happens during the day, such as a med not in the drawer when you go to get it, you make a note to yourself using this sheet, to recheck later. assign a specific time to every event. which specific time doesn’t matter as long as there is one!

Florence Nightingale herself once said that for a nurse, learning to use pencil and paper was far more important than learning to use a stethoscope. Okay well, we’ll teach you the stethoscope too, but this Brain is what the pencil and paper are for!

There is an old rule that if you get your stuff done, and become known as a person who always completes their tasks, you will be rewarded by being assigned more tasks the next time.  You can not possibly achieve this state of bliss unless you use a checklist. The staff nurses always make snap judgements regarding the students – if you prove to them that you are using this, they will be positively impressed. They hate it when you fail to do something and then also fail to communicate with them. If you’re not going to be able to do something, you can use this tool to estimate what that would be and then tell the staff nurse in advance, which will safeguard the patient from problems. We are all  part of the team!

Using your brain is a key to college – using the Nurses Brain is the key to successful nursing!

tomorrow: part two: checklist culture and your role in quality.  There is a lot of attention being paid to this issue, and if you are the kind of nurse who makes “to-do” lists, you will succeed in nursing and in life.

don’t miss this next one! subscribe to this blog now!

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What I learned from hiking (in 2010)

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I let my beard grow while hiking in 2010. I shave it these days to hide the gray! I hadn’t been on a long distance hike like this in ten years, at the time. The summer for me was a series of section hikes while got in shape to accompany my younger daughter on her through-hike.

The guy who played accordion for my old polka band, Tom Jamrog, is also a long distance hiker and backpacker. He’s done the “Triple Crown” – the AT, PCT, and CDT. He blogs about his trips, and has a vigorous writing style. He recently posed a question on his blog; “what have you learned from Hiking?”  and I decided to answer.

Troop 4 Marlboro, Algonquin Council B.S.A., Camp Resolute

I have been a hiker and backpacker all my life, ever since Boy Scouts. Growing up, my mom generally refused to let us ever play inside the house, even in winter. “So what if it’s cold, put on some mittens and your winter boots and go outside and play!”  and I vividly recall games the neighborhood boys would play in the woods around our house or on the nearby golf course. Usually some variation of Capture The Flag.

As a youthful prank, my friend Kenny Paul and I once threw some firecrackers at the house of a neighbor boy.  (Yes, it was us – the Statute of Limitations has run out, and besides, I think I was eleven years old.) The boy’s mom called the police.  Ken was the star of the crosscountry team, and when the cruiser pulled up with blue lights blinking, I was surprised that I could keep up with him. Two cruisers spent some time in our neighborhood while Kenny and I spent the next three hours eluding them in an apple orchard. hmmmmm……. Later this inspired me to join the cross country team. I ran the the half mile in spring track.  (2:14 was my personal best, if you really must know).

Kenny recently retired from his position as an officer in the United States Marine Corps, and he still is a runner.  My older brother finally rediscovered Kenny’s whereabouts after thirty years. Ken was also an excellent baseball pitcher. Once while on a training run though the neighborhood, a dog came out to chase. Kenny picked up a rock and beaned the dog from fifty feet away, knocking it unconscious. What coordination. I laughed when he told me his USMC specialty was artillery. He spent his adult life throwing stuff at people…..

Misery in the Great Outdoors

Camping with the Boy Scouts included a lot of miserable experiences amidst the fun. I never cooked for myself at home before going camping and trying it there. Baking my first potato in a campfire was half-burnt/half-raw, for example, and one memorable hike during a winter weekend, our patrol ploughed our way through thighdeep snow for three miles on a hike to nowhere. Ultimately I got Eagle Scout. why? mainly because my older brother had done it, and I looked up to him ( still do!).

sash

every Eagle Scout has a merit badge sash. I got twentyone as you can see – the exact number required for Eagle. For each, I can remember who the counselor was, what the activities were, and other trivia.

Other experiences

To answer the specific question, It’s hard for me to separate hiking from Boy Scouts, in terms of what I learned. Don’t disrespect the Boy Scouts – I have some philosophical differences with their current leadership, over their policy toward gay persons and atheists (each of which are just fine with me) but overall the Boy Scouts  fill an important  need. Paul Theroux summed it up for me when he described his experience with the Boy Scouts.

Taking a side trail

During the time I was in Maine I did all the outdoorsy stuff – crosscountry ski, canoe ( the Allagash and Upper West Branch of the Penobscot) , hike, telemark, etc. I climbed Mt Washington and Katahdin in wintertime more than once…. but by comparison, the last few years in Hawaii I went through a period of not doing nearly much adventure-type stuff in the outdoors. Oh well, yeah, I was spending every summer time in rural Nepal teaching with Christian Medical Missionaries and taking day  hikes, doing the Asian Travel thing (no, I did not climb Everest at any time…….that’s the usual Nepal question I get from fellow backpackers…)  and here in Hawaii I was going to the beach (Sandy’s) and dayhiking… but .. it wasn’t the Real Thing. And the weather here is so nice that it’s missing an element …….

Passing it on

I always took my kids on outdoorsy adventures. Glad to have two daughters because then the pressure was off and I knew I would never have to be an adult scout leader. I was saved from having to spend any more weekends with bunches of eleven-year-old boys. (thank you God!) but taught both my girls all the skills anyway. Yes, both my kids learned to make a fire, paddle a canoe, predict the weather by looking at the clouds, and read a topo map. When they were six and eight, we took them on a weeklong canoe camping trip, retracing Thoreau’s path on the Upper West Branch of the Penobscot River in Maine.  When the younger one announced her intention to do a through-hike of the Appalachian Trail in 2010, I was reminded of  long-ago solemn promise made at a campfire,  that I would join her on that quest, should the day ever come.

My daughter, “Whoopie Pie,” on the trail. Much of the A.T. is a long green tunnel. After only a few weeks, Whoopie Pie was doing up to thirty miles a day, often four or five days a week (!) – It’s never been about mileage for me.whoopie-pie-on-trail-2

 

My 2010 hike

When the summons to hike long-distance came, I was old. And fat.  But this served as a personal challenge to get into enough shape to be a respectable hiking buddy. And that’s where the learning began again. In order to keep up with Whoopie Pie, I decided I would do my own solo hike for a few hundred miles and get in shape before hand. And besides, she didn’t want to do the whole thing with me, she was going to hike her own hike. So in May I started off in the hundred or so miles that traverse Massachusetts, averaging eight miles a day through the Berkshires. A few days to recuperate and restarted in Vermont, about two hundred miles through the Green Mountains and into New Hampshire, by this time averaging eleven miles a day.  Another hundred through Shenandoah National Park, and finally co-hiked with Whoopie Pie. By the end of the summer I was not so fat; and I learned that I was not so old, either. I hiked 475 miles in that summer.

Highlights

I think most writers focus on the physical challenge of doing this,  but most of the highlights for me were a bit of the meditative variety, and a good hike serves as a daydream for a long time afterwards. A variety of mountaintops in seven states. Hearing loons on a pond on Vermont, for the first time in five years. The night at the Tom Leonard Lean-to listening to nesting hoot owls.  Cleaning the dead leaves from a mountain spring, and the wonderment of finding a fist-sized jellylike clump of frog’s eggs. The evening Julie and I lay in our bunks in a cabin in Vermont listening to the soft conversations of other hikers during six days of cold rain in the Green Mountains. The “problem bear” at Shenandoah when I was the only person in the lean-to that night. Having heatstroke on two occasions. The bedazzlement of thousands of  butterflies, a cloud of butterflies, in a dewy meadow of wildflowers in Shenandoah National Park. Being sick with bronchitis and experiencing SVT overnight after taking cough medicine, wondering how I would get evacuated from such a remote place. Walking out on my own the next morning.

And of course – Smarts Mountain

The people who comprise the subculture of the Trail are always a highlight, and I learn a lot from them. One day’s hike sticks out.  I got to the FireWarden’s cabin at Smart’s Mountain New Hampshire at the end of a fourteen mile day, knowing for the last five miles that I needed to beat an oncoming thunderstorm. The approach from the south is very steep, with iron rungs forming a sort of ladder over the steepest sections. The rain pelted down, forming a waterfall on the trail as I ascended. At one point my heart sank when the clouds parted and I realized I was nowhere as close as I thought I was. Darkness was approaching and I needed to skedaddle. Lightning was hitting less than a halfmile away as I got above timberline, dashing the last half mile like a frenzied animal.

To get there I had elected to hop past the Trapper John leanto, but to my surprise I was passed from behind at the last minute by Roaring Lion and Snow White,  a pair of through-hikers who had hopped past two leantos, and come from six miles even further south than me that day. I was sprinting after a fourteen miles day, but they were sprinting after a twentymile hike. wow.

On the porch, one other guy who’d come from the north, was already cooking dinner.  The cabin smelled of dead porcupine but the roof was intact. RL, SW, and I each got out of our clothes and did what all long distance hikers do – get into the dry sleeping bag, eat something, and regain some strength. As we lay there we agreed that the lightning was – exciting. Thank God I was smart enough to know how to keep the bag dry.

Everything I learned in Boy Scouts told me not to do what I just did.

Then we had dinner, and the usual bull session as we got to know each other. We shared that special  cameraderie of people who know that what they just did, (hiking uphill into a lightning storm,) was crazy; and yet, who know they are also in the company of others equally crazy.

Best summed in a saying

A friend is somebody who will bail you out of jail. A best friend is somebody who in handcuffed on the bench next to you saying “man, that was awesome”

(with kudos to my buddy Cameron Allen in Pueblo). Later that same summer, I did a 22 mile day in Shenandoah National Park. And a few other feats in which I picked up the tootsies and put them down. The highlight was to hold my own when I finally caught up with my old hiking buddy, Whoopie Pie.

From then on, for the rest of that summer, I knew: I can still push myself, further and harder than I thought. Miles, time, space, vertical elevation, weather: meaningless.

And I have some best friends. On the Trail.

Addendum

If you got this far, and you want to read an adventure tale that starts with a trek in Nepal that went horribly wrong, check out my second book:

9781632100085-SOTG-Nepalt.indd

If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at https://goo.gl/PGTW30

 

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part two: About Hawaiian Culture for the Travelling Nurse

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Review of “Peoples and Cultures of Hawaii: The Evolution of Culture and Ethnicity”

Welcome to the Islands

When I moved to Hawaii seven years ago, I attended an orientation for new faculty at the University where they said “you either love teaching here or you hate it.” In that cohort of faculty was a blond-haired blue-eyed woman with a German accent hired to teach in one of the science departments. I did not see her again until running into her on campus seven months later when she told me she was leaving “the students here are rude and disrespectful and I have not had a successful experience. Every day is a struggle to get their attention.” I thought back to that orientation session… in the intervening time I was having a terrific cross-cultural experience learning about Asian cultures and what exactly it was that makes a classroom at the University so different that one on the mainland. Clearly, here was a person who was not able to grasp the interpersonal insights and skills we’d spent time talking about that day, and which were a continual thread to the discussions of how to help students in my department. I guess that helping her address these issues was less important among faculty in her department.

Reach out to Multiculturalism

She was not alone, and in the intervening years there are many other examples of people who either “get it” and enjoy this special place, or who just can’t quite fit in, and don’t have the tools to figure out how to cope. This extends beyond faculty at the University into every sphere of work. Of course, in some areas you can structure your work day and your life in such a way that you never come in contact with anybody who is not a “haole” – if that is the case, you are missing out on the richness and cultural heritage here. If you can learn and grow, Hawaii is a wonderful place to enjoy world cultures and the unique local culture. I truly believe Hawaii is a model for the rest of the USA in terms of how to realize that we all are persons and we all deserve respect on our merits, not just on a stereotype.

UH has an office named The Center for Teaching Excellence which helps faculty to make the adjustment to teaching in the islands. In a parallel way, I expect the UH Medical School (known locally as JABSOM) to continue their rich tradition of multicultural sensitivity and inclusion. The first edition of the book “Peoples and Cultures of Hawaii” was a solid effort in this regard, published in 1980. I’d written a review of that one a couple of years ago, since I felt that it was better at addressing Hawaii-specific issues than the usual textbook resources on cross-cultural nursing. This second edition came out in 2011 (while I was in Nepal, on an entirely different cross cultural quest…) and is due to be a beacon of hope to all medical sailors seeking harbor on our shores. Aloha!

Take a Peek

A nice feature of Amazon nowadays is to see the Table of Contents and peek inside the book; for that reason I will not repeat here what you can read in the author’s own words. The book seems to be about twenty percent longer, and chapters have been added on some of the more recently prominent immigrant groups from Asian countries that had barely been on the radar in 1980 (Cambodians and Koreans, for example). A wider variety of contributing authors are included, and often the writer is from the group they are describing. There is a glossary of terms from the anthropology literature in the back, seemingly designed to give medical practitioners a more solid footing to describe the friction points in acculturation, etc.

For these reasons, I think this book should be handed to every MD, RN, RPT, or medical professional of any type who comes to the Islands, along with their Hawaii license.

Suggestions

Now, all of this is not to say that the book is still perfect. From the nurse’s point of view, I wish that some of the chapters had been written or reviewed by nurses; I think the perspectives of medicine and nursing are different, and that some very practical tips on how to interact with patients and families would have improved this. For nursing, one of the main resources on cross-cultural interaction is Lipson & Dibble (from UCSF) and they too categorize each cultural group by country-of-origin; The nursing schools here tend to use that one as required reference books for student work that includes obeisance to the cultural origin of the patient at hand… with a little different focus this book would have had every right to supplant these others as the index text for this subject area.

Eye contact – or no?

Next, one of the friction points in general communication between persons from the mainland and persons from an Asian culture is body language – such things as how long to wait for an answer when you ask a question, how far apart to stand, eye contact, etc – these things are very specific and though they often sometimes vary from one Asian culture to another, they constitute an area to work on. For that reason, I think a “how to” on this subject would add.

“Local”

The book makes an excellent effort to look forward – where do all the cultures go from here? But did not really look at the underclass and the “locals” as if they were a distinct subgroup – which they are. The youth of today are not major consumers of health care in the way that the elderly population would be, and youth culture evolves at the speed of light – but I would have loved to read the authors’ assessment of this. Of course, this is a moving target, and today’s “Jawaiian” craze could be obsolete long before the 3rd edition rolls out. I wish there was a website specific to this book where the authors could archive some of the updated web resources on subjects such as pidgin.

Addendum April 10 2012

One of the nifty things that happens at the school of nursing where I teach is when students do a video project for the community health class. Sometimes these end up on YouTube. Click here to see one which I think is particularly good. The student who plays the role of the Filipino lady in this video, deserves some sort of oscar – not just for  the acting, but for the sense of humor which is so evidently on display.

In summary, your preparation for Hawaii should consist of more than just the Lonely Planet Guide. Get this one!

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How to avoid the Nursing Work Culture From Hell

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Culture at the workplace?

A workplace becomes a surrogate family for the people who spend time there. When people spend so much time together, the personalities come out. A group will adopt a set of informal rules that guide each day. This becomes “workplace culture.”

If you have been a nurse for any length of time, you develop a sixth sense for this. The minute you walk on to the patient care area, you get a vibe of what it’s like there.  It may be calm and peaceful, it may be chaos, it can be happy or tense. It can be this way independently of how much nursing care the patients require. When you interview for a nursing job, be advised: the best managers know about workplace culture, and they are looking to add staff who will value it and honor it. A theme of this blog has been to encourage new nurses to live up to their caring potential, and it includes caring for those around them as well as for the patients.

Urban Community Hospital – a “war story”

My first nursing job was not a place for teamwork. It was an “urban community hospital”  and chronically understaffed. Each shift was a contest to see whether you could get through all the work yourself, and the assignment was heavy. It was a trauma ward, lots of gunshot wounds and stabbings and victims of beatings, along with a population of heroin addicts and homeless persons. Lots of crime victims. The staff consisted of a head nurse who had worked there since the dawn of time, and each spring there was a fresh crop of new graduate RNs. The hospital would hire a batch of new grads all at once, they would stay a year, then leave once they got “the golden year” of hospital experience. Or at least they were planning to leave then; most left my particular unit before hand, chewed up by the system of unsupportive coworkers. The crew of nurses aides were all older than the young RNs.

Walking Rounds

We did “walking rounds” there, change-of-shift report consisted of a procession of sorts, all the nurses in a group  following the kardex from bed to bed like it was the Bible at the beginning of Mass. The circus was led by the head nurse, same age as my mother. She generally arrived each morning with an attitude, and would heavily criticise the night nurse, pouncing on any inconsistency she found between the way the patient looked and what was written in the kardex; or how the story was presented.  Very theatrical. As report was read, she would examine each patient (“you said the IV was NS w 40 of K, why is it I see a bag of LR hanging?”) This included getting on her hands and knees to look under the bed, on occasion, as well as barbed sarcasm. Every day.  One day she chased a rat out of the ward, to the cheers of the rest of us…. but that is a whole nother story ( it was a very large and well fed rat). Yes, she was teaching us how to have standards and to follow them; but nowadays we would call her approach “horizontal violence’ or “verbal abuse” or “eating the young.”  That was the way it was in that time and place.

These days there is a national movement toward something called “Magnet Culture” – hopefully to eradicate that sort of approach. UPDATE: a former student emailed me after reading this, to alert me to some excellent work published by Sigma Theta Tau about Bullying in the Nursing Workplace.

New RN working nights

I was on eight-hour shifts, a day night rotation and soon found myself working nights about eighty percent of the time – the only time I was on days was on the head nurse’s weekend off.  The day I passed my Boards I was Charge RN whenever I showed up from then on. That was how I spent my first year as an RN. Since I was on nights so much, it meant that I got to be the person going through the gauntlet every morning. And yes, I did well at it – better than the others. In those days I could be just as sarcastic and unforgiving as others. I would spit it right back at the head nurse, to the astonishment of other first-year RNs on the crew.

I no longer treat others that way.

The usual night staffing was two RNs for up to thirty patients, and even then, I went out of my way to help the other RN be ready, which was appreciated. I promised myself I would never be the kind of nurse manager  that I was now working for, and that if I ever had anything to do with it, I would be kind and respectful.

In other words, it was the Work Culture from Hell. Got the picture? I can go on and on – you got me started, but like a bad dream, I need to wake up and remember that this degree of dysfunction is not the way to go through life. Let’s focus on positive ways to interact, here.

Teaching workgroup culture. learn it and live it.

What I do now is to incorporate healthy work behaviors into nursing school. Nursing school is not simply to learn about patient care; it’s to learn the way a professional person acts and thinks. Sometimes in the Fundamentals lab, a student acts as though the only thing they are there to accomplish  is to learn how to perform a specific skill according to the checklist. They don’t care whether others also learn, and don’t help their classmates or spend time coaching somebody slower to grasp the concept. Somehow there is a subset of students who think it’s okay to be a jerk to those around them while they focus on their own learning needs. This may work for Jack Sparrow, but will not lead to success in a hospital workplace.

This tells me that such a student has a learning opportunity.  Focusing on yourself is not the way to go through life. You are missing a major part of the ride.

(Note: a few years back I developed a one-page handout for how to act in the nursing school lab which I will send to anybody who emails me and asks for it)

How to Succeed as a team

Want to develop the habits of a helpful work group culture? here are some ideas. They are not a “Code” – more like Guidelines.

In both lab and clinical: Your work is not finished until the work of everybody is finished. Nobody sits down until everybody is able to sit down. If one person is getting swamped, we pitch in and help them. In the lab, it’s the students and faculty together, who tidy up and make the lab ready for the next group of students. Don’t rely on somebody else to clean up after you.

In the clinical setting: learn about  each other’s patients. Depending on how morning report is handled, this can be a challenge. If it’s a group report that’s easy; but if it is nurse-to-nurse report, you have to go out of your way to do this.  Find a way to check in with the other staff nurses (or the other students) after an hour or so.

Nobody lifts or transfers any patient by themselves.  There is a strong evidence-base out there regarding nurses and prevention of back injuries, so we have an important reason for this. Some wards have many “heavy” patients, and this attitude makes a big difference. But it’s also a chance to create and strengthen relationships among the staff.

say thank you. this goes a long way. there’s an old saying that “People may forget what you did or said but they won’t forget how you made them feel.” think about it.

use names. there is a parade of people through every hospital area every day. Learn who they are, and use their name in conversation.  You don’t have to go to Happy Hour with them or learn their kids’ names, but why not humanize the workplace? this includes housekeeping, the docs – everyone.

name tags. Ever been in a college class where the professor never learned your name, even by the end of the semester?  At my nursing school, we teach the same course to a different cohort each semester, there are fiftysix or sixty new names to learn. On the first day I always set up a system of using name tags, keeping them at the lab. The students collect at the end of each session. We call each of the students by name. They are not allowed to melt into the woodwork, which is often a surprise for the students.

just like a basketball team
Huddle. this picture was taken in Nepal, but any of my students will recognize this gesture. When I wave my hand at waist  level, they know that I want them to approach. I never have to raise my voice when calling them over. (and yes, they know i will not bite…) At lab and clinical practice,  I call a huddle every now and again. soon the students learn to call their own huddles without me.  Communication is a big part of teamwork. We use the time to share and to plan out our work and get ideas.

The Bottom Line about workgroups

The fact is, we all have a choice to create a healthy work culture, or not. which will you choose?

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part one: Guide to Hawaiian culture for the Travelling Nurse

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Exotic Hawaii?

I have a friend from the mainland who thinks Hawaii is really really exotic. and I suppose, compared to Indiana, it is. Then again, Indiana would be considered exotic in its own way if an anthropologist from some other country were to visit there. For me, having lived in Nepal, the answer would be – no. Pretty bland compared to Patan. We wonder why people think Americans ( the WASP kind) are arrogant? it’s because they(we?)  assume that the yardstick culture, the frame of reference by which everything is to be judged, is the one “they” grew up in. (whoever they may be….)  There’s a great poster from Syracuse Cultural Workers that applies, here.

Images from TV

Ask yourself what your image of Hawaii is. Chances are it’s from television.  Or maybe the movies. The Chamber of Commerce here is alway thinking of ways to promote Hawaii on the mainland. It’s no accident that the Pro Bowl is played here. (In January when everyone else is freezing.) What is Hawaii like from the inside?

For Travelling Nurses

Anyway, there has always been a subculture within nursing, of Travellers. Nurses with specialized skills who come to Hawaii for an exotic experience.  Now that I have been here seven years, I feel comfortable enough to compile a quick guide to cross-cultural nursing as applied to Hawaii. Particularly Honolulu.  Every nurse that goes to nursing school here already has learned these things.

The first question is, How did everyone get here? Honolulu is the most “majority-minority” city in the USA, the only state where European descendants have never been in the majority. You expect to find Hawaiians here, and 40% of all Hawaiians in the world, live on Oahu, as is fitting. but they are now a minority.

Yes, this is an issue.

Resources

IMHO, the best book on Hawaiian culture is Peoples and Cultures of Hawaii, written by two guys from the John A Burns School of Medicine. UPDATE: I am pleased to report that a new edition of this was released in 2011 –  There is only one review of the 1980 edition written on Amazon, but I think that reviewer knew what he was talking about,  it is incredibly insightful. The book is a classic, I will run down to the store and get the new one!

From a sociological or anthropological perspective, nurses absolutely need to learn about and respect the culture of which ever person they are caring for.  Frankly, that has always been something I loved about nursing. The variety of manifestations of the human spirit is what makes earth a great place.

Most nursing school nowadays require students to buy and use a reference book on this topic. Many of these books have a section on Hawaiian culture.  And also about Nisei, and about Pacific Islanders and Samoans.  All well and good. There is a gap in the professional literature. When we assign students to ask about the culture of a given client, they sometimes come back and say

“Well, he said he is part Pordagee, Hawaiian, Chinese, Filipino and Swedish. What do I put down on the assessment form? do I have to look up all of them?”

“Nah, just put down ‘local’

Local?

So then the question becomes, “Is there a distinct culture known as ‘Local’ around here, and if so, what is it?”

It’s a chapter waiting to be written in the edition of all those cultural atlases. Take note: whoever wishes to tackle this can become famous in a scholarly way. I do have to warn you: this is a minefield of political correctness. Be prepared to be flamed.

I don’t think I am the one to write it, but I will give suggestions to whomever is brave enough to assume this task.

Pidgin

First, language. There is a specific dialect of English spoken here, known as “Pidgin.”  And yes, you will hear it spoken, but only if you listen carefully. Pidgin, or “local talk” is also, a loaded political subject, since the colonialist Americans tried to eradicate it. You can find it on YouTube.  Because of the musical inflection of pidgin, it is not possible for a person from the mainland to fake it and pretend they are local; but if you are here you need to learn  how to enjoy it. I also highly recommend the book “Pidgin to Da Max” as a hysterically funny guide to the subject. There are examples on YouTube.

I suppose that Rule Number One rule for any person from Da Mainland would be, never assume that a person speaking pidgin lacks intelligence. ( a terrific link!)  Think of pidgin as a whole different language which just happens to contain elements of English. In fact, college students often are able to slip in and out between the King’s English and Pidgin just as if they were two different languages.  The decision to use one or the other is very sophisticated, situationally driven, and a conscious one. Because of historical active discrimination against pidgin-speakers, if a bilingual Pidgin/English speaker thinks you are condescending toward them because of it, you will find your job here much more difficult. Trust me.

A student of mine who was Asian, had studied on the mainland ( Nebraska!) for a year, and she said that one of the reasons that she came home was, she was tired of the fact that the Nebraska-based students assumed she didn’t speak English well. She said that prior to that experience, she never considered whether Asian-Americans could be the subject of racism. It had simply never occurred to her.

The former Saint Francis Hospital had a rule about language: The official language of the hospital was English, and employees were forbidden to speak any other language in the daily conduct of their work. Think about that one. The patient population was multicultural in a dazzling way, though, and if the patient initiated the conversation, it was okay. The staff there was capable of greeting them in the same multitude of languages. Actually, it was something I loved about working there.

Rule Two

Which leads to rule number two: learn about the culture of your coworkers, just as much as you learn about the culture of the patients. After all,they are probably one and the same. We had a new faculty person from New Orleans, Louisiana – a fascinating and wonderful American culture all of its own. One day at class break, I asked for volunteers to teach her how to fold a paper crane…. and ten students happily shared time to talk with her about origami and what it meant for them. Wicked cool.

Rule Three?

rule three is – “chill.” as in learn to chill.  (read every definition!) Be advised, this is also the most “Asian” City in the USA. Certainly the most polite of any city I have been in, and I have lived in a few. The most respectful and mellow. If you drive like you are in Boston or New York City, you will have a problem on the roads here. Here you will learn patience and how to enjoy a gentle sense of humor.

Food – sometimes only Zippy’s will do!

Next is food. there is a distinct Hawaiian cuisine, known as the plate lunch. You can get rice for Breakfast at McDonald’s.

I would be remiss if I omitted some of the great comic talents of Hawaii that are able to examine and poke fun at their own culture. Then of course, so much of cultural knowledge consists of little tidbits; discrete factoids that we would call “Pearls of Wisdom”

The North Shore is Going Off!

There is a distinct surf culture in Hawaii.  Subject of a whole nother blog.

Please share widely and feel free to comment.

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Filed under Honolulu, nursing education, nursing faculty jobs in Hawaii, Nursing in Hawaii