Monthly Archives: August 2012

In Defense of the living, breathing professor – and patient

link to an article in the Wall Street Journal, titled “In Defense of the Living, Breathing Professor” . In brief, he is saying that there is flawed thinking when we measure college education by “output” as if we were making widgets on an assembly line.

The author makes the point that human contact is the key element of education. He’s a physics teacher.

Nursing education certainly needs to incorporate active coaching on a one-to-one level as we impart the process of patient care. Nowadays we are more likely to use simulated learning ( “Sim-Man”). We are more likely to develop sophisticated scenarios such as the Heart Association has used in ACLS classes for thirty years. This is all well and good,  but it reminds me that I  have been meaning to write something similar to my esteemed colleague from Williams College. My own essay would be titled “In Defense of the Living, Breathing Patient.”

Does this apply to clinical?

you bet it does.I do think that the faculty need to be actively involved in assessing and caring for every patient assigned to their students, particularly at the beginner level, and that faculty need to model a level of engagement that promotes the idea of how to change the plan when you go “off script.”  For this, faculty need to be experts in clinical practice.

Nursing faculty shortage?

This takes careful planning. I think we have a national infusion of new faculty who are uncertain of this role. Those of us who are older faculty members need to find the means to share what we know if we are to create the best environment.

I think I will write future blogs on the subject of technology and the human element. In the meantime, welcome back to school!

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Filed under Nurses Brain, nursing education, Nursing in Hawaii

Nurse Burnout, adrenaline junkies, and secondary stress, part deux

Q: What kind of bird are – you?

note; the underlined words or phrases are hyperlinks to related background material. be sure to to click on these.  especially the one related to my book about Nepal.

Burnout happens.

Got a lot of responses to my last blog posting about Burnout, Marlene Kramer and stress. It got mentioned in the AJN blogroll of nursing blogs which is titled “Off the Charts. At that location, they keep a list of blogs by nurses. Some are quite good.

The editor there called me “peripatetic” –  not a word I use every day. Moi? Come to think of it, I don’t spend a lot of  time trying to describe myself.  The words that come to mind are handsome, witty, charming, emotionally available, and compassionate.   :-)   and of course, humble!

Urban Dictionary

so naturally I went to the Urban Dictionary. For those of you in search of eternal youth, this is a terrific site. I would have never learned the meaning of “4-20 friendly” for example, if I had not used that resource. And of course, the place includes current commentary on issues of the day, such as this gem.  (Like the vast majority of Americans I don’t think we should elect male legislators who think they are the only ones qualified to tell women what to do with their bodies. I have spent too much time with too many crime victims to laugh at their expense.)

1) The act of, relating to, or given to walking about;
2) Moving or traveling from place to place to freekin place;
3) Snooking around touching every damned thing around;
4) Cant sit still or settle down; and
5) Constantly, without rest, surveying, reconing, and otherwise annoying the hell out of everyone by any of the above actions.
Okay, well – I don’t have just one theme for this blog. I get up and think new thoughts every day. Or try to.
Today’s thought about Burnout, Secondary Stress, OCD in nursing, codependence in nursing,  and self-care in nursing
In the past blog, I reviewed Marlene Kramer’s four stages of burnout, and I focused on assessment of yourself and others. I didn’t really get into detail about some of the other things I think can help you if you are having problems with this.
Riding the Dragon is a book by Bob Wicks, a professor at Loyola College in Maryland.  It’s about developing resilience in every day life despite uncertainty. Pretty simple wording that you could use to meditate upon, I suppose.  My two cents? when you are health care professional, sometimes your work calls you to deal with a darned big dragon!
He’s written a bunch of other books.  I met him and heard him speak when he visited the Catholic Campus Center of the University of Hawaii.  I had the opportunity to speak with him afterwards, and was delighted to receive a copy of one of his other books in the mail two weeks later. This one was titled Overcoming Secondary Stress in Medical and Nursing Practice: A Guide to Professional Resilience and Personal Well-Being.
My review of this book:
In my experience as a critical care nurse and also as a hospital manager and  teacher of nursing, I have dealt with issues of secondary stress for many years
and I have seen many victims of this problem. And so, I stay abreast of this issue.On Page 5 of the book, the author says:”it’s a ‘one-sitting book’ designed to distill current clinical papers and research; provide proper guidelines to avoid and/or limit unnecessary distress; strengthen
the inner life of physicians, nurses and allied health personnel; and offer recommendations for further reading on the topic. If nothing else, its goal is
to raise awareness that secondary stress is a danger..”and I think this nifty little tome fills every one of these these goals and more. In a survey  book, Dr. Wicks has managed to distill the best suggestions, on a very practical level, into something that’s readable and deceptively simple. I say deceptive, because he has a way of describing the profound thoughts of stress, death,
burnout, and spirituality into an engaging style.It is readable and has many anecdotes to which a clinician will relate. He makes excellent use of summarized bullet points, and checklist style formats to present ideas. I found myself thinking of all the people who need this as a christmas present.

in short: highly recommended!

There are gradations of burnout.
I gave my copy of the secondary stress book to one of my best students, who is a perfectionist and highly “driven.”
The phrase “burnout” gets thrown around a lot and can lose it’s meaning. Sometimes a person simply needs to talk with a coworker for a couple of hours away from work; other times they need a two-week vacation; but in extreme cases the person gets a glimpse of the horror that life can be for some of the people we meet, and goes into a state of full existential angst.  we can all benefit by creating a work environment that sorts through these issues.
Perfectionism as a related problem or symptom
I do think there are nurses who bring an insidious type of emotional baggage with them, who are more at risk of the total-despair variety of burnout. These are the ones who are needy about proving their worth by being excellent caregivers, but they get it mixed in with caretaking. Also known as co-dependent, experiencing co-dependency. Manifested also by perfectionism and OCD on the job.  For these persons there are a couple of really good books. One is an oldy-but-goodie “I’m dying to Take Care of You: Nurses and CoDependence.  The other is Codependent No More: How to Stop Controlling Others and Start Caring for Yourself.
Work Environment
a final point: the books above mainly deal with how to identify stress and burnout within yourself but do not really go into the management skills and sensitivity needed to create a supportive work environment.  If you have a manager who tries to suppress the staff’s ability to deal with stress collectively, you need a new manager. Honesty is a key to effective problemsolving.
Let’s be realistic: if you deal with trauma and sadness all day at work, you need help from those around you. period. If  the team is one which gives you the message that you are on your own or that somehow it’s your fault,  your stress will be magnified.

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Nurse Burnout, Reality Shock, Marlene Kramer

note: all words or phrases that are underlined lead to hyperlinks – be sure to click on them and see what happens ;-)

The B word?

In my recent blog about adrenaline junkies, I got a private message reply asking for advice: What if you were an adrenaline junkie now verging on burnout?

Well, naturally my first reaction is to tell that person to go to Amazon and buy my book about nursing in Nepal. One basic premise of the book is to explore what happens when you are a lifetime adrenaline junkie and you finally get to a problem so big, so overwhelming, that God can’t even deal with it. Yes, such problems exist, and yes, God has a special way to address them over the course of time. There is an answer – but you will have to read all the way to the end.

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at  http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/

this book is about medical missionaries in Nepal. sure to become the number one beach read for summer 2014! go to Amazon and pre-order your copy at
http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/

you could also buy my second book. see picture of the cover at left.

Marlene Kramer,RN, PhD

I read a lot of papers written by nursing students on the topic of burnout when I teach the senior-level leadership, management and issues classes. I always check to see whether the person was diligent enough to find the book “Reality Shock: Why Nurses Leave nursing” by Marlene Kramer. This one is old by now – written waaay back in the 1970s – but it was such a classic that it still deserves to be studied and cited. (note: On Amazon there are only three used copies, and the minimum price is $199.50… go figure…). In fact, one Google source indicated that it has been cited 743 times in subsequent scholarly work. Dr. Kramer is now retired but had a long distinguished academic career. Her work on reality shock and burnout created a national dialog at the time which led to the work of Patricia Benner and others.

Kramer and Magnets

There were many who thought that Kramer portrayed nursing in a highly negative way, and this reaction produced a result that is still evolving today. The argument was “Okay, you have showed us what is wrong but why can’t we focus on the good things that are happening?”  Which is of course, what a reasonable person would ask.  Nursing advocacy, the heart and soul of what nurses do, is based on righteous indignation and the desire to make things better, and so Dr Kramer was firmly in the tradition started by Florence Nightingale herself.

Magnet Hospitals

The reaction to Dr Kramer caused the American Nurses Association to promote the studies about magnet hospitals – places where the new nurses were being nurtured and developed. and from there to the whole Magnet Nursing Service movementThere is now an independent non-governmental agency which evaluates hospitals that voluntarily apply for Magnet Designation.  Can we agree that this is a good thing? We still have a long way to go, and the budget climate is not helping us, but an argument could be made for saying that Kramer gave the entire profession the wake up call that led to this work. She got the ball rolling. Every hospital should have a Magnet Nursing Service.

Return to wallowing in negativism

back to burnout. There are four phases.

the honeymoon. This is where the new nurse is still being oriented and everything is wonderful. The preceptor is so smart! The staff is amazing! The paycheck is HUGE! we all love to be around such a person and delight in the innocence of youth.

crash and burn. the onset of this is hard to predict, but usually about the six-month mark. Takes place when the nurse starts getting feedback from every direction, not all of it is easy to take because people are telling him or her that they are not perfect. The nurse is now saying “These people are jerks. This hospital has its priorities wrong. nobody is listening. Why did I ever want to be a nurse?”  This person can be angry and depressed.  Nothing is wonderful anymore. The road has a fork in it. One choice is to leave; the other choice is to stay.  When the nurse  leaves (regardless of where they go), it  causes the cycle to repeat with new nurses.  Turnover of this nature is expensive for all concerned. The National Council of State Boards of Nursing has recently recognized that up to 25% of staff nurses who do get a job, leave their first position within a year, which has caused the NCSBN to work on what they call “Transition to Practice” issues. In this way, we wonder if anything has changed since the 1970s……

recovery.  This is a phase of letting go of anger and depression, characterized by the return of a sense of humor. The preferred outcome of crash and burn.  The nurse wakes up and realizes that some things are good, some are bad and not everything is perfect. Or Burnout the nurse quits the job and goes to another job (to enjoy another honeymoon!) or maybe leaves bedside nursing altogether.

and resolution. where the nurse develops a sense of perspective and is able to contribute effectively.

The Care Plan for the Nurse?

The key is to assess yourself and those around you, and adopt some specific interventions.

the honeymoon? keep the new nurse grounded in reality. No, it’s not as perfect as you think

crash and burn? similar to above. No, it’s not as bad as you think. Hang in there and keep working at it!

recovery? find new ways to be productive now that the new nurse has been around the block.

and resolution? find joy and happiness in leading your life, with nursing being just a part of it…

Water over the dam

There’s been a lot of work on related topics since 1975. For example, the whole “codependence” thing came and went – the more codependent the nurse is, the more likely they are to experience burnout.  Closely related to this is the idea of OCD, and I gave my two cents on this in a prior blog. We have had periods of cost-cutting when a new wave of managers rejected efforts to nurture and  mentor new nurses through their role transition issues. Sometimes it feels like all the negative and positive trends are now stewing in the same pot…..

The Bottom Line

Probably the most important lesson is that you may go through these phases by yourself, but you are never alone. Use your peer-group resources. Each nurse has to start by assessing themselves as to where they lie on the four-phase continuum. Keep your sense of humor, and keep your self open to sharing with others.

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Nurses have a lot at stake if Obamacare is repealed or the Ryan Budget is enacted

August 22nd Update: is there anybody left who thinks the GOP is not waging a “war on women?” If so, click on this link.

Please share this widely. here is the link to this blog: 

http://wp.me/p1Kwij-fb

In the interest of full disclosure, I am a partisan Democrat. Have been all my life. I am committed to defending the underdogs of society.

Last spring I wrote a blog on the subject of Obamacare, saying that we need to keep it. I quoted an NPR radio piece where the economic specialists described how it seems as though health care is pitted against spending money on building roads.  Road-building is “men’s work” – somehow this means it is more valued by legislators than “women’s work????” – I just don’t think so. I am old enough to remember the Reagan Recession of 1982 in which households where the main breadwinner was a single woman were inordinately affected. I know lots of nurses who are single parents….. let’s think of a better way….. ( and by the way – Reagan was not such a great president….)

Then I left for the summer. The Supreme Court ruled in favor of the Affordable Care Act.

Hooray!

But the last shot has not been fired. Nobody should relax and think that the provisions of reform are safe.

The latest thing is The Romney/Ryan plan to replace Medicare with a voucher program. Ugh. Please do click on the link!!!!

Here is a YouTube Video from the Obama campaign, which every nurse needs to see:

http://youtu.be/0QQxGEQm6Qo

We have a problem with vouchers. In brief, they are highly unlikely to cover enough of the costs, and people will be responsible to pay out-of-pocket. Paying out-of-pocket serves as a means of forcing people to self-ration the care they receive.

I know many senior citizens who are committed to never be a burden to their children, and who will go without needed services before asking their kids for money.

I also know many adult children who are caregivers for a frail elderly parent, and who spend a lot out-of-pocket even though they now have Medicare.

I have met women who have put off care for breast lesions because they were hoping it wasn’t cancer – and when it turned out that it was, they suffered needlessly because it was too advanced to treat. Metastatic breast cancer is not a happy way to die.

Reality

The reality is that money doesn’t actually cure anything; it’s the nurses and doctors and drugs and treatments that do the curing. All these things will disappear when the money dries up. Nursing agencies including home care, will close. Hospitals will close or cut back.

Here is a place where nurses need to educate the public as to the effects of cuts. Please share the video link widely.

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Nursing student advice – are you an adrenaline junkie?

please share. as we start the fall semester, it’s time to think about the challenges ahead

ACLS again
I spoke with a nursing student yesterday who took ACLS this  summer during an internship, and she told me two things. First, during the class she loved the competitiveness of trying to “win” the ACLS scenario. Next, during the internship she saw the practical applications of ACLS at work, and she profoundly agreed with one of my previous blogs in which I wrote that the main idea of ACLS is to prevent the need for such intense intervention and to be pro-active.

Then she said it: ” I admit, I am an adrenaline junkie.”

I laughed. Been there done that.

Adrenaline produces a “rush”

Most people have heard the term, and way way back in 1991 there was a movie named “Point Break” in which the hero went out of his way to experience danger.  (oddly enough, that particular movie combines big-wave surfing with bank robbing and skydiving.)

In the TV show “ER,” every time they showed the team responding to a cardiac arrest or trauma code, the soundtrack would ramp up, pulsating and flashing.  ( nobody supplies a similar soundtrack in real life, except occasionally there are surgeons who use a playlist in the OR to keep the team relaxed – creating the opposite effect and enhancing “flow”)

With the growing popularity of women’s sports, as evidenced by the Olympics, more nursing students come to the profession with a background of knowing how to compete and wanting to “win.”

Here is a definition of adrenaline junkies

Adrenaline junkie is a colloquial term used to describe someone who is addicted to thrilling and fear-inducing situations. The act of conquering fear creates a rush of endorphins that is simultaneously energizing and relaxing. This natural high leads adrenaline junkies to seek out ever-bigger thrills and excitement.

Some adrenaline junkies place themselves into dangerous situations. Others prefer to know that they are physically safe, but pit themselves against obstacles that make them feel unsafe. Halloween events and roller coasters particularly appeal to adrenaline junkies.

And of course, a self-assessment

You can determine for yourself if you have the tendencies to become an adrenaline junkie, here is a self-test that focuses on your present approach to life.

Maturity

And of course, the paradox. First, you need to be pumped up and “on it”  in order to deal  with emergencies effectively. Second, in the long run, you need to cope with stress and to develop a mature approach. If you are a young student, there is an undeniable appeal to all the technical details of high-tech nursing care, and when you are in your early twenties you are at the peak of brain power in terms of training your memory. At some point though, you will need to engage in self-care activities, setting limits on your own stress-seeking behavior.

the answer

Naturally, I have a ready-made solution for you… a two part prescription.

the Nurse’s Brain.

If you are using a Nurse’s Brain, you already have a major tool for keeping your stress level in check.  You need to adopt this tool to gain the skills needed to step onto the playing field.

balance and – mindfulness

Taking inventory of the stressors and dealing with them. Whenever I have been with critical care nurses and somebody outside the ICU suggests this, the response is always eye-rolling and incredulity – every critical care nurse knows that simple stress-reduction techniques are not enough unless they are coupled with a clear-eyed approach to the challenges of clinical practice. In other words, at a stressful clinical site, the management and team members must all participate in effective problem-solving. All the meditation and Kum-Bye-ah in the world will not help the stress unless you have supportive coworkers and an effective manager.

But seeking balance in your life, affirming the good things and valuing your own self, are still the way to go.

http://stress.about.com/od/situationalstress/a/adrenaline0528.htm

http://stress.about.com/library/adrenaline/bl_adrenaline_self_test.htm

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Nurses and OCD (Obsessive Compulsive Disorder) – is it good or bad?

Note: please consider subscribing to this blog, and sharing with friends. It’s easy. there are little buttons in various places. click them! and – read some cool reviews of my book.

Why WordPress is a terrific blog host

I am  satisfied with WordPress as a blog host. I like the interface and the themes. Did you know that when you own a blog, you can access the statistics as to the number of hits? WordPress helps me see how many hits I get (highest was 479 in one day!) or which countries the hits originate from (about 110 countries – nearly everywhere except China and Francophonic Africa) or how many hits each entry received ( the blog about “myths of Nurse Practitioner education” was surprisingly popular). It’s a great way to get feedback in ways that go beyond waiting for a comment to appear or not.

But one intriguing thing is, I get a daily list of search terms that somebody typed into their machine and which somehow led people to this place.  There is one particular topic I have meant to expand upon and now is the time.

Obsessive Compulsive Disorder among nurses

I think this shows up because I wrote a series of blogs about the Nurses Road Map and I observed that attention to detail, ability to execute a complex plan, and work with checklists, is a trend that is not going away. To some degree, we are raising a generation of new nurses to be checklist-users. The field of nursing informatics is designed to sift through the mountain of clinical details available at the bedside and help the nurse get through all the little events of the day (while keeping track of the big ones). Anyway, there is an online quiz you can take to evaluate your own OCD. Most nurses will laugh at this because it highlights the relationship between fears of death or disease and the development of OCD; for the lay person this may seem irrational but for nurses the fear of catching a fatal illness can be entirely rational.

Now to the meat of this blog

The short answers, not based on science but based on a lifetime of observation.

OCD While in Nursing School

 1) A little bit of OCD can be helpful. As a nurse, you are accountable for followup on things you are told, and this includes organizing patient care. Read my blogs about the Road Map, please. it is my gift to humanity ( though I did not invent it)

2) too much OCD  is disabling. True story: I once worked with an IV nurse (i.e., specialized in intravenous infusions, all day long, starting, hanging meds, and running them including hyerpalimentaiton and Chemo rx) who had every symptom of OCD. She once spent fifteen minutes starting an IV on a person who had died. without noticing the lady was not breathing. Fortunately, the patient was a Do Not Resuscitate. But still……..I would have noticed, myself.  If you have OCD you can get wound up by little details and lose sight of what is important.

3) nursing school is a place where you will get feedback on how much OCD is too much.  We have all heard the war story about the straight-A student who could not actually function in real life. If you are in nursing school now, look around. You will most likely see people who are extremely persistent and meticulous. This is the kind of student who argues with the professor about every single exam answer (should it matter if they are already getting an A? experienced people know that there is no such thing as a perfect exam); asks questions in class about obscure medical syndromes (let’s focus on commonly occurring things, shall we?) and is consumed by the idea that “this is important what if somebody dies because I don’t know this?”   ( not likely. trust me). Ask yourself who in your class is dealing with OCD.

Sometimes the faculty are a bit timid and don’t call out Obsessive behavior. They are not doing the student any favors by letting it slide. I had a student not too long ago who thought it was okay to phone or email the faculty with questions at all hours, and who got huffy when there was no immediate reply at 0300 on a Sunday. Hot tip: this is not a way to impress the faculty.

4) clinical with real people is the place where the rubber hits the road. Often, a student with OCD will relax and start to “get it” when they go to clinical, because this is the ultimate place to “test reality.” You can’t always predict every single thing that will happen in clinical, not altogether a bad thing. Nurses benefit every time they meet a patient who demands that the plan fit the patient’s expectation, not the nurses expectation. As an aside, we have a new emphasis on simulated learning these days – using tightly written scenarios with expensive mannikins. When we do this, we delete the possibility that there could be a  useful  serendipitous encounter between a student with OCD and a patient who demands flexibility. The richness of the actual clinical milieu is not to be taken lightly. Simulation is like eating beans; clinical is like enjoying cassoulet…… beans are still part of a good cassoulet but there is so much more……

5) A crisis is not always a bad thing. Let me describe that another way, giving an example. Sooner or later, it’s a common occurrence in nursing school that the clinical day does not go anywhere near the way you planned it, and you feel like a failure. For a student with OCD, this gets magnified into a total crisis, because they often have the belief that they can or should control everything. ( if I can’t be perfect  I should not even try!)

Don’t let “perfect”  be the enemy of “good.”  If the faculty person is wise, this time becomes an opportunity to discuss the zen of staying on track and a whole lot of other higher-order-of-magnitude stuff. A crisis can be a “teachable moment.” Often, a breakthrough. A good way to look at ways to keep OCD in check.

In the Workplace

As I said, some small degree of OCD is probably desirable, but too much is not helpful, and it would be great if everyone got a handle on this before entering the workforce. It does not work that way in real life.

1) don’t take the work home with you. One of the great aspects of effective use of a Nurse’s Brain is that when the shift is over, you can feel good about not missing anything, and clear your mind when you walk out the door.

2) If you have OCD and you are on a nursing team, my personal experience is that you can make life miserable for everyone around you. Other nurses may have a different style of work, and if your OCD causes you to be inflexible, you will descend into madness. I will be blunt: Nurses with OCD tend to become critical of others and to engage in what Marie Manthey called the “Three B’s”. There needs to be limits on this behavior.

3) OCD is not a leadership skill. Sometimes a staff nurse with OCD is chosen to become a charge nurse or nurse manager. This is nearly always a mistake. A person with OCD lacks the ability to weigh and evaluate the relative imprtance of things, and tends to see everything in black and white.

The Great thing about nursing

I will edit this blog entry over the next few days, but the clock is ticking and hey, “it’s good enough now.”  For so many schools, fall semester begins in  two weeks or so, consequently I will hit the Publish button for this first draft.

The great thing about nursing is that to be a good nurse is to call upon your own capacity for healthy problem-solving behavior and healthy coping which keeps OCD under control…….

June 2014 update: click here for a link to an excellent blog about how to cope with anxiety if you are a nurse.

share your reaction in a comment……

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Filed under Nurses Brain, nursing education