Five New Year’s Resolutions for Nurses

Posted on December 29, 2011 by Megen

I dislike New Year’s resolutions, mostly because people ask what they are, and then when I inevitably fail at them I beat myself up about it. Normally I set my standards too high. “I will go from being a couch potato to running a marathon by March, and I will go from eating ramen noodles and cereal to cooking three times a day immediately, starting January 1.” Or they are too nebulous. “I will eat better.” Or I shy away completely from setting goals for myself, because if I don’t have goals, it’s impossible not to meet them. “I don’t do New Year’s resolutions” is my version of “bah, humbug.”

Goals, resolutions, call them what you want, are nevertheless important both personally and professionally. If we as a profession don’t know where we’re headed, probably we’ll stay where we are, and most of us seem markedly unhappy with that. Still, we would rather stand still and complain about our lack of movement, much like the couch potato who complains about never having time to work out. Our professional organizations have organized goals for us as a group, but we can have our own too.

What resolutions can nurses make that are achievable, yet not too nebulous?

  1. Are you unhappy at your current job? If so: “this year, I will apply for one new job each month.” Whether you get offers or not, taking action brings a sense of accomplishment. And applying for jobs tends to have a strange domino effect that lands you in a better place you never would have known about had you not explored.
  2. Is there a certification you want or need but haven’t gotten around to studying yet? If so: “this year, I will become board-certified in my specialty.”
  3. Are you distressed by conditions at your workplace? If so: “this year, I will become a member of our department’s unit-based council.”
  4. Have you become a part of the problem by gossiping, talking behind your coworkers’ backs, and helping out less and less? If so: “this year, I will not talk about anyone who is not physically in the room, and I will confront every person who acts unprofessionally toward me.” This one can be black-and-white because otherwise it is a slippery slope. Integrity (that’s what not gossiping, letting people know when you’re bugged by them, and doing what you should be doing as a part of a team—the first thing that drops off when you’re mad at your colleagues all the time—means) is a habit and cannot be developed by halves. That said, any improvement is always better than failure to try, which, I’ve heard, is the only true failure.
  5. Are you, like many nurses, remiss in your self-care? If so: “this year, I will work out three times per week and eat at least two servings of vegetables per day.” I set the bar on this example very low because it feels as if most people don’t work out at all or eat any healthy food whatsoever, so baby steps are the way to go. If you made just those two changes for an entire year, think how much healthier you’d be.

The point is to pick something you can meet or not (not something such as “I’ll work out more”) and something you feel can actually be done. If you don’t have the time and money to spend studying for board certification, just acknowledge that and don’t say you’re going to do it. Choose another goal. But choose one.

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Nursing Over the Holidays

Posted on December 26, 2011 by Megen

We’re on the home stretch with this year’s holiday season, but this week can be the most difficult one of the year for those of us in health care. We ourselves have probably been working (possibly extra to cover our colleagues’ vacations) and also meeting family obligations or even taking time to relax and enjoy ourselves. Our patients tend to be sicker because otherwise they would not be in the hospital over the holidays. This week, we will be performing damage control for the last few weeks, culminating in treating the amateur drinkers and MVC and assault victims on New Year’s Eve, and we’ll be doing routine care more than usual because primary care practices will be closed some or all of the week.

The very nature of holidays increases the likelihood of hospital visits and stays. People are traveling, so they get in wrecks, and they often do it far from home and are correspondingly more stressed out about it. They ride in airplanes or cars for long distances and get blood clots. They eat more, and they don’t eat the healthiest of foods. Those with clogged arteries eat the last straw on the cholesterol camel’s back and have heart attacks, so cath labs are jumping. Those with congestive heart failure eat too much food that contains too much salt and come in fluid-overloaded. Diabetics figure a few extra pieces of chocolate or a few more sugar cookies won’t hurt (it’s the holidays, and they deserve a little treat) and end up in DKA.

Often families visit their loved ones in long-term care only a few times a year because of distance and travel issues, and the holidays are typically one of those times. They see grandma for the first time in a year and are alarmed at her condition, so they bring her to the ER. Grandma may not be any sicker than she normally is, but if her children haven’t seen her for a year, the difference may be notable and shocking, so she ends up in the hospital just by virtue of someone noticing.

On the lesser end of the spectrum, you’ve got your food-preparation injuries (watch those electric carving knives and be careful dicing vegetables, and deep-frying turkeys is a fad that needs to go, because people come in with grease-splash burns) and gift-opening injuries (why people think it’s a good idea to use an X-Acto knife to open troublesome blisterpacks is unclear to me). You’ve got your new-toy injuries (you really can shoot your eye out).

On the worst end of the spectrum, our patients die on or near a holiday, and we know that that holiday will forever be associated in the family’s memory with the death. As nurses we can find these deaths even more difficult emotionally than we usually do. There is something particularly poignant and distressing about coding a patient while a family dressed for midnight Mass waits weeping in the hallway or having to deliver news of a fatal diagnosis to a patient during the holiday season.

To top things off, this year the flu season seems to be getting off to a late start, so healthcare professionals are starting to get sick as well. What can we do to buckle down and get through until January 2?

  1. Remember there is an end in sight. Soon.
  2. Be grateful we’re on the right side of the nursing station: it’s much better to be a nurse than a patient.
  3. Go out of our way to bring holiday cheer to our patients giving up their holiday season to be in our facilities.
  4. Take care of ourselves. Hospital break rooms are loaded with fatty, sugary, salty foods, and it’s all too tempting to snack throughout our shifts. Sick nurses can’t help anyone.
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Five Benefits to Becoming an RN

Posted on December 22, 2011 by Megen

I knew I wanted to be an ER nurse when I was 8 years old. I read all the books I could get my hands on about Florence Nightingale. I used up all of our Band-Aids on my Cabbage Patch dolls, and I rigged up little slings and pretend casts with paper and gauze and set up a little outdoor trauma bay under the huge tree in our front yard. My mother was not pleased. “Why do you want to be a nurse?” she asked. “You can be anything you want.” This was always followed by “you can be a doctor or a lawyer,” so until I was about 15 I thought those were my only two options.

Why, indeed? At the age of 8, I wanted to be a nurse because it simply felt like a calling, and for what it’s worth I think that’s as good a reason as any. However, becoming an RN has definite upsides. Here are five.

  1. Fabulous effort-to-payoff ratio. Have you ever been cold, afraid, and in pain in a hospital where you feel lost and then a nurse brings you a warm blanket, gives you medicine to take away your pain, and sits at your bedside (with or without holding your hand or giving your shoulder a reassuring pat) to explain what’s going on? If so, you know that those things mean the world. Nurses do that. Those tasks take me about 3 minutes. In what other profession can you spend 3 minutes and cause such a huge uptick in someone’s feelings of well-being? That’s what I think of as the effort-to-payoff ratio. A second pillow, some footies, or a few well-timed ice chips can feel like a miracle to a sick patient and take almost no effort at all.
  2. Pay. I realize that this is relative, but I feel like I am paid appropriately most of the time for the work I do. I have enough money, and I work only three times a week. It’s a solid acceptable workable profession, financially. Also, nurses generally have multiple opportunities for callback pay or picking up extra shifts; it is easy to make extra money when you need it.
  3. More patient time. Doctors see patients for 5 minutes or so and then chart. Nurses see them the whole rest of the time. I realized a long time ago that if “I want to help people” was really my goal, I would have to help them by being a nurse. Dozens of healthcare professions involve patient contact, but RNs are constantly actually at the bedside if they want to be.
  4. Always something new. That said, nurses don’t have to be at the bedside. They can do research, become managers or administrators, enter informatics—the possibilities for nurses keep increasing.
  5. A schedule for everyone. Up before dawn? Work days. Night owl? Work nights. Don’t like being a rut? Work swing shifts or for an agency. RNs who are night owls (like me) have a particular advantage, because it’s easier to find open night shifts and when you do they pay a shift differential that can go up to approximately $6 per hour above your base rate.

Probably I couldn’t have come up with this list at 8 years of age when asked “why would you want to be an RN?” But it’s a good profession. What they say is true; it’s the hardest job you’ll ever love.

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Three Nursing Trends to Watch Out for in 2012

Posted on December 20, 2011 by Megen

We’re almost to the end of 2011, and with the advent of each new year come resolutions and curiosity about what is coming our way. The healthcare industry is changing furiously, and as nurses we are on the forefront of the changes. I don’t like change. It makes me nervous. However, at a hospital think tank recently, I brought up questions and concerns about all the changes in nursing and what they might mean to us individually and collectively, and I’m glad I did because I left feeling reassured. My Director of Nursing, who has been a nurse in some capacity for close to four decades, said, “I can’t tell you how many times in my career we nurses have said, ‘This time the changes will be too much.’ But we always come through it, and things work out.” Our profession may change, and our day-to-day responsibilities may change, but nursing is likely to remain the same at base. We will always help our patients’ responses to disease.

That said, the healthcare industry is butting up against some important deadlines involving Medicare reimbursement and HIPAA/HITECH (Health Information Technology for Economic and Clinical Health) requirements. A detailed listing of these changes warrants a book-length treatise, but in short, the industry has less and less time to implement changes to all-electronic medical records and to emphasize outcomes and patient satisfaction for reimbursement. Some of these changes have been gradual, but for institutions who have lagged, they could be rushed and abrupt, and nurses will do well to look ahead and prepare themselves.

Therefore, here are the top three trends I see in nursing for 2012.

  1. More electronic charting. Still writing flowsheets or clinical notes on paper? Don’t get too set in your ways. It’s all got to go electronic by 2014, so the window is shortening. It doesn’t matter whether you work in a 500-bed hospital or a one-physician office. Luddites need not apply. Cozy up to a computer near you and get comfortable with it if you’re not already.
  2. More and more with less and less. Providers are seeing decreasing reimbursement for the same services, and I’m guessing that trend will continue. Tying reimbursement to patient satisfaction can only be a vicious circle; less revenue means less staff and less-qualified staff, which will decrease patient satisfaction, which will decrease income, which will decrease staffing. Those of us left on the floor will therefore have to figure out how to make our patients happier and happier while we get busier and busier and have fewer resources to help us.
  3. Back to school. Hospitals are increasingly either requiring a BSN as an entry to employment or are incentivizing the BSN. Nurses with an ADN are flocking to BSN programs to avoid getting the ax, to obtain a raise, or to seek employment in settings that require the BSN. Other nurses who have their BSNs are going back to school en masse to become nurse practitioners, thinking that soon-to-come changes in the healthcare arena will result in increased use of midlevel practitioners. Medical literature leads one to believe that the lack of family care physicians has reached a crisis point, and many nurses believe that nurse practitioners will admirably (and profitably) fill the resulting niche. Otherwise, many staff nurses have simply had it with cutbacks and unsafe patient-care ratios and are returning to school to escape.
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The Joint Commission Noticed We’re Tired After Long Shifts

Posted on December 15, 2011 by Megen

The Joint Commission just issued one of their reports (available here with a free Medscape account), and this one states they’ve noticed we make mistakes when we’re tired and this is bad for patients. It is interesting that rules exist for physicians and medical residents regarding how many hours per week and how many hours in a row they can work, but to my knowledge none exist for nurses. Also interestingly, in this report the physicians chafed at the rules, indicating that they prevent needed continuity of care. I wonder how nurses would react if similar rules were handed down for our profession.

At least in my area of the United States, nurses work 12-hour shifts for the most part. For floor nurses, that generally means 14-hour shifts by the time you include report and tasks that have run over and have to be done. Anecdotally I would say that younger nurses complain bitterly about the fatigue after these long shifts but react srongly negatively at the idea of shorter shifts and working more than three shifts a week, whereas older nurses are more open to the idea of returning to five 8-hour shifts. All nursing opinions I have personally heard revolve around the shifts’ effects on us and not on the patients, although they are related: the article notes “a pivotal 2004 study of 393 nurses on more than 5300 shifts showing that those who worked shifts of 12.5 hours or longer were 3 times more likely to make an error in patient care.”

Three times more likely. That worries me. Nurses, how many times do you spend less than 12.5 hours at work for your 12-hour shift? Not very many, if you’re like the nurses I have worked with. A factor ignored in all the studies I’ve read on this subject is commuting time, too. Many nurses drive up to an hour to get to work. That adds 2 hours of awake time to every shift worked, and I know from the one job I had for which I commuted that that time does make a noticeable difference in fatigue.

The alert quotes a nurse from Atlanta:

“‘We have been slow to accept that we have physical limits and biologically we are not built to do the things we are trying to do.’

According to the Joint Commission alert, exceeding those physical limits can result in an extensive array of problems that can compromise one’s ability to provide optimal care, including memory lapses, an inability to stay focused, compromised problem solving, confusion, impaired communication, slowed or faulty information processing and judgment, diminished reaction time, and indifference and lack of empathy.”

When I started reading this alert, I assumed it was yet another report on how night shift was bad for you, but it doesn’t distinguish night from day shift—just lengths of shifts. As a veteran nightshifter who experiences more fatigue during the day, I find that refreshing. Dayshifters, you are not immune. We all need to pay attention to how we are faring during our shifts and take action if needed. The Joint Commission alert suggests things like naps, which are not going to happen, but usually we can arrange to go outside for a few minutes and just escape from the unit and swing our arms around to get our blood moving. A change of scene and some movement can really make a difference. Each nurse seems to have his or her own tricks for perking up, and it seems we need to be using them more. I don’t want to make three times more mistakes because I’m not alert…do you?

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Staffing Ratios (Should) Matter to Everyone

Posted on December 12, 2011 by Megen

Twitter has seen a flurry of conversations and complaints from nurses about nurse-patient staffing ratios lately, and the issue is also being pushed further out into the public eye as patient satisfaction is tied to hospital reimbursement and as changes in the healthcare system necessitate constant belt-tightening. Nurses have cared deeply about staffing ratios for some time, but circumstances are such now that everyone needs to. Well, only everyone who might ever be hospitalized, which is pretty much everyone.

At first my interest in staffing ratios was theoretical. We discussed them in my leadership class during nursing school. We discussed the California staffing ratios, which are mandatory and therefore unique in the profession, and we debated over the pros and cons of having nonadjustable ratios. It was all very ivory-tower.

That ivory tower crashed around my ears and led to my abrupt exit from my first nursing job. It was in a cardiac ICU, and I loved it. I’m a cardiology junkie, and I have always preferred critical care areas. When I started working there, it was an acuity-adjustable unit, which in practice meant that I could have patient assignments ranging from one fresh post-CABG (bypass surgery) patient to four patients who needed little more than telemetry observation. It was a good system because a patient could return from bypass surgery and stay in the same room until discharge instead of being shuttled from an ICU to a stepdown unit to a medical unit. All of that changed with new management, who failed to tell the staff about the changes.

I went to work one night and received my patient assignments as usual. There were four. I went to that pod and started reading the charts: all four were either brand-new fresh post-CABG patients or within 2 days out from open-heart surgery of some kind. It was an obviously unsafe assignment, so I told the charge nurse, thinking she had just received incorrect report. No. They’d changed the acuity system, meaning we would have four patients regardless of acuity and they would be assigned by pod rather than acuity (I could have landed one fresh CABG patient and three telemetry patients, but I didn’t only because of the room assignments). I objected on grounds of patient safety and was told I had accepted care of the patients by taking the slip of paper with my assignments on them; if I refused to care for them, I would be charged with patient abandonment and reported to the state board.

That struck me as unusually underhanded (“unusually” only because I was new). I was terrified and angry. I worked that shift basically praying that nothing went wrong, because as it was I had to leave basic tasks undone. I couldn’t monitor my intubated multiple-drip post-CABG patient even close to how she should have been. In the morning I quit. I wasn’t going to put my license on the line even one more time—our licenses are on the line with unsafe patient ratios because if something goes wrong, it’s under our watch. We accepted the assignment, as was so starkly pointed out to me by my charge nurse.

In my current job, we have fair and safe staffing ratios for the moment, but we’re always told that’ll be changing. I know it will. I know very few nurses who haven’t thought about leaving the profession because of this issue. The thing is, the administrators tell us we should be grateful for our ratios. I say the patients should be. Safe staffing ratios allow safe nursing care, and anything other than safe staffing ratios does not. Unsafe nursing care results in bad patient outcomes. Anyone could be that patient.

We all need to care about this.

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Why Do We Ignore Pain in Children?

Posted on December 8, 2011 by Megen

I just read “1 in 5 Limb Fractures in Children Receive Delayed Care”, and it ties in to my reflections recently on undermedication of pain in children. A close friend’s young child had surgery followed by a complication necessitating hospitalization and was clearly undermedicated for pain throughout the entire experience, despite her deliberately requesting treatment for his pain. She is not an ambiguous person, either. I’m sure the nursing supervisor and possibly the hospital CEO were involved in her complaints.

I remember from my ENPC (Emergency Nursing Pediatric Course) curriculum reading alarming statistics about undertreatment of pain in children. In the course, we discussed possible reasons for this from the medical provider standpoint. Children express pain differently, and those of us who are not solely pediatric nurses are not as finely attuned to how children communicate. Also, evidently some children cope with pain by totally shutting down and dissociating, so if you use one of the behavioral pain scales developed for children it will give you a much lower score than the actual pain should give. Preverbal children are unable to tell you that they are having pain or where it hurts or how badly it hurts; older children may not tell the truth for various reasons based on their developmental stages. All that aside, we as providers fall down on the job because if our patient is not telling us “I hurt, and I need something for the pain,” it is evidently not as far up on our priority list as it should be. Perhaps our mnemonic for priorities should be ABCDP (airway, breathing, circulation, disability, pain).

That experience and material aside, I read the article I mentioned about the limb fractures and researched undertreatment of pain in children, and to my surprise I found that the parents were the ones not bringing the children in to have fractures evaluated and not medicating them at home after procedures. I assumed before reading these articles that nurses and doctors were the ones responsible, because of what I’ve learned through my own education, but research indicates that not only are we failing to medicate children and address their pain while they’re in the hospital, but also we are failing miserably at educating parents in medicating them once they leave.

As for parents not bringing children in for evaluation of fractures, I’m at a bit of a loss. This study suggests that parents don’t take children’s pain seriously enough. Is it that children routinely bump and bruise themselves and cry, so parents are not aware that this is a different cry? I don’t have any ideas about how to address this specific problem or similar ones, other than it seems clear that nurses who work in areas where we are likely to encounter pediatric patients need to educate ourselves about children’s pain and their expression of it and find a way to educate parents about it—particularly if the child has had an operation or some other procudure and will require medication at home. We need to do a much better job making sure parents understand indications, dosing, and side effects to alleviate their fear of giving the child pain medicine, because studies show that parents report undermedicating their children out of fear (of addiction, oversedation, and so on).

This is an issue. Pediatric patients are not just little adults, as we all learned in nursing school, and they come with built-in secondary patients (their parents).

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Bullying

Posted on December 7, 2011 by Megen

One of the first things I heard in nursing school when I started clinicals was that “nurses eat their young.” I suppose it was intended as a helpful warning, but nobody who said it told me what it meant or the depth of what it meant. I’ve since learned that nurses eating their young is really the tip of a sinister mountain of vicious, bullying behavior in this profession (we call it “lateral violence” to make it sound nicer, but it’s still bullying). We are extra-special mean to nursing students and new nurses, but being an experienced nurse provides no exemption from being “eaten.” Bullying is in the news lately as an issue not only in the nursing profession, but also in general, as several young students have committed suicide to escape from bullying (navigate to http://google.com and type in “suicide bullying” for a disturbingly long list of articles about teenagers killing themselves because of bullying).

Nurses are grownups and not teenagers, but the very fact that any human being is willing to end his or her life rather than continue to endure bullying testifies to the serious nature of it. This is not a minor issue or something that can be relegated to that long list of “things we can address when we have time.” Bullying can erode a person’s self-worth to the point that she wishes to die. The evidence is there. To me, that means we need to pay attention and not hide behind quips or aphorisms (“well, nurses DO eat their young” is tantamount to simply shrugging off the problem; it is dismissive and serves only to decrease the issue’s perceived importance).

Even if we as a profession are not concerned about one another, we should be concerned because bullying hurts our patients. In 2008 the Joint Commission issued a Sentinel Event Alert (“Behaviors That Undermine a Culture of Safety”) stating such. The document begins

“Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team [emphasis mine].”

The entire document can be downloaded in PDF form here. It is not long, is worth a read, and lists examples of “disruptive behaviors” (bullying) in health care. It is important to note that the document reminds us that bullying can include both “overt” and “passive” behaviors. In other words, if a coworker doesn’t answer your phone calls, you may feel silly for calling that “bullying,” but the Joint Commission would back you up. That’s a passive behavior that is undermining patient care—and probably your self-esteem, maybe your desire to go to work, and possibly ultimately even your desire to be a nurse at all.

Nursing is a difficult enough profession to handle in and of itself. The nature of a job that necessitates mastering constantly changing up-to-date technical knowledge and skills combined with doing less with more financially while providing compassionate, therapeutic care to our patients and their families would make it stressful even with the constant support of our coworkers and managers. Without that support, and beyond that, with the active opposition to it, the stress can be insupportable. We don’t need to lose nurses (or patients) to this issue. It’s time to go back to what we all learned in nursery school and play nicely together in the sandbox and share our toys.

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I Washed My Hands: Did You See?

Posted on December 1, 2011 by Megen

Reuters just published an article (“When cameras are watching, more doctors wash up”) on hand hygiene. Hands up: who’s heard that hand hygiene is important? I think we all have. This article interested me for several reasons:

  1. It did NOT study the effects of hand hygiene on infection rates. In fact, it quoted an infection-control expert who said that whether or not hand-washing prevents infection hasn’t even been proven. I find this intriguing. Perhaps what they meant was that it hasn’t been proven that washing your hands within 10 seconds (the criterion for a “pass” in this study) or that following other randomly stringent criteria prevents infection.
  2. It included doctors and nurses. Most studies on hand hygiene focus on nurses. This one gets kudos for recognizing that doctors go from patient to patient too. I can’t tell you how many patients I’ve had in isolation whose doctors don’t mask or gown, as if only nurses can contribute to the spread of infection. And I think everyone has heard the story about how the germiest place in a hospital is a doctor’s tie (this topic has been oddly extensively studied; here is a representative summary of one study). I’m glad, therefore, that studies like this one are including physicians; they should therefore also include CNAs and housekeepers—anyone who goes room to room can take microscopic critters from room to room.
  3. The conclusion seemed to be that we will wash our hands if we know we’re going to get caught out otherwise. In other words, healthcare workers can be trained, like rodents, with basic behavioral techniques when logic and education fail.

The third point deserves further elaboration. Why do we need an external carrot-and-stick system to make us wash our hands? Preceding points about the questioned efficacy of hand-washing notwithstanding, current best practice remains to perform hand hygiene before and after patient contact, before and after glove use, and pretty much before and after you do anything. Currently, as far as we know, washing our hands and using the hand disinfectants is best for our patients, so I don’t understand why we aren’t doing that. We shouldn’t need the knowledge that we’re on camera and our “fails” are going to be pointed out to us to motivate us to do something we should be doing anyway. Semmelweis promulgated hand-washing to decrease infection rates in 1847, so it’s not as if it’s news to us that hand-washing and disease are related.

Are we lazy? Do we think our hands are bacteriostatic? Granted, I think some of the statistics they throw at us are skewed and based on bizarre science. For example, if I have just rubbed foam on my hands as I leave a patient room and walk straight into another room without touching a curtain or a doorknob but I don’t foam up again before performing patient care, that’s a “fail” technically. Logically, not so much. Still, this study is a good reminder that we should have clean hands. It may not be exactly saving lives, and probably we don’t need expensive video surveillance to implement it, but hand-washing is still a good idea. Let’s do it more.

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Euphemisms

Posted on November 29, 2011 by Megen

AJN published a post on their Off the Charts blog entitled “On Euphemisms and Learning to Be Present.” The point of the post was really about a student experiencing her first death, but as luck would have it I received an e-mail from a colleague who was ticked off at a provider largely traceable back to a communication difficulty caused by an ability of them both to call a spade a spade. The combination made me wonder how much trouble we could avoid if we put more conscious thought into our use of euphemism and softening things up.

Most nurses are still women, and multiple linguistic studies have repeatedly found that this is just a fact: men and women communicate differently. Some differences are that we tend to be more indirect, to dance around subjects, and to soften our requests with long introductions (“If you have time, do you think you might be able to…?”). We tend to consider the possible results on the hearer of what we are about to say. We pick up more information (interpreted correctly or not) from the body language of the recipient of our communication. I’m not saying men don’t do any of this. I’m just saying nursing is still a female-dominated field, and that has to have a bearing on the general communication patterns in that field.

How much effect do these patterns have on patient outcomes, though, I wonder?

The AJN blog was over a common issue in medicine: should we say “die” or some other word? If another word, which one will have the least negative connotation for the patient and family? There is no way to know. This is only one of dozens of euphemistic issues in everyday nursing, though. “This is going to pinch a little” actually means “it’s going to hurt.” And “you might feel some discomfort” means the same thing. The urge to soften physical blows by words may be a disservice to our patients. For myself, if something is going to hurt, I want to know about it. In my practice, I am forthright, particularly with children (“this needle is going to hurt, but if you hold still, it will be over quickly”). I don’t see that as a particularly common practice, unfortunately.

As for the larger issue of unclear communication through a desire to avoid hurting the other person’s feelings, we are dealing with life and death. Do we need to worry that much about our coworkers’ feelings? I’m not suggesting we go around saying mean things or any little thing that occurs to us; it is, however, possible to be both civil and forthright. “I was wondering if you could possibly double-check the orders you wrote for the patient in room 14 when you get a chance” and leaving a doctor to guess what she’s supposed to be looking for is not as helpful or efficient as “I’m concerned the dose of medication you ordered may be incorrect for this patient’s weight, and before I give it I would feel much better if you could please check that the order is correct as entered.” I don’t think that’s rude or inappropriate, and any doctor worth his or her salt will realize that they (and computers) err and be happy to stave off a medication error at the start. This is the kind of example that would have solved my coworker’s ire—all the situation needed was both parties stating what the actual questions and issues were, but nobody did.

As for whether patients “die,” “expire,” or “pass on,” I can’t even begin to address that. It’s individually patient based as well as probably culturally and geographically influenced. I say “die.” But whatever we say, we should put more conscious intent into it.

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