Family Matters Part 2: A Guide for Patient's Families

Being in the hospital is not only stressful for patients, but it can also take a toll on family members as well. There is much evidence to support that involving patient's families in their care not only reduces the level of stress of the patient and family, but also aids in decreased lengths of stay and higher patient satisfaction (you can Google "patient family centered care" and read whatever scholarly articles you wish if you don't believe me). As a nurse, regardless of whether or not you believe in patient centered care is irrelevant; patient satisfaction is where it's at. I can tell you that the the current hospital system I work for as well as many others I have encountered, are focusing more on patient and nurse satisfaction more than ever before. Many hospitals have opened visiting hours to 24 hours a day, have started purchasing cots for family members to sleep in, have developed and trained nurses to function as family support teams and have even begun throwing patient's ice cream socials upon discharge!!! (I don't agree with the last event, but if it makes em' happy...) The healthcare system is evolving, but the nurses themselves are lagging. I can tell you that we are doing our best to accommodate families but sometimes the family members themselves can be very difficult and un-realistic. I have come up with a few general rules that family members can follow to meet the nurses half way as we become better at delivering patient family centered care:

1. If you are calling to check in on your loved one, please try to call after 8am or 8pm. Nurses usually give report to each other around 7am. This will allow us to assess your loved one before you call; this way we can give you a better idea of how they are doing. If you want to know how their night went, you can call before 6am to speak with the night nurse. 
2. It is illegal for us to give people patient's information over the phone unless the patient gives us authorization to do so. Often times on admission, the hospital will provide you with a pass code that you will have to give us when you call before we can release any information to you. If you don't have the code, you don't get any info; and please do not hand out the code to everybody and their mother. Make one person the contact person and all other family members can call that designated person for updates. The more time we spend on the phone, the less time we spend in the patient's room. 
3. When you are visiting your family member in the hospital, please keep the visitors to around 2 at a time, especially in the ICU (other floors might not care as much). There isn't much room in hospital rooms and there tends to be a lot of equipment.
4. Especially in the ICU, check with the nurse before stimulating or engaging with your family member, especially if they have recently suffered a stroke, a head injury or are on a ventilator. Is is important that the brain not be overstimulated in order to heal. When patients are on ventilators, we like for them to be calm and relaxed in order for the ventilator to do its job. 
5. Patient's are in the hospital usually because they are sick. I know sometimes family members feel like being with them all day so they are not alone is beneficial, but in reality a lot of patient's tell me to kick out their family members so they can sleep. Put yourself in their shoes, if you were at home sick in bed, would you want visitors coming to see you all day, probably not. It's okay to go home, even at night. If anything should happen, we can call you. 
6. If you are with your loved one as they get admitted to the hospital from the emergency room, we will kindly ask you to step into the waiting room while we get the patient settled. This is a privacy issue. Often times we take their clothes off, look at their skin and go over some personal history questions. Some people don't want their family members in the room during this time. As soon as we are done, we will come and get you. 

These are just a few suggestions. The healthcare system is working on improving our patient family centered care practice. We will not perfect this overnight or even in the next decade. Be patient with us and kind. Express your concerns in a professional and courteous manner. Ask to speak to the charge nurse or family support team if you have concerns about your loved one's care. Most nurses love taking care of people, all people, including families, but we also like to be treated with respect. 

A Moment of Truth

To my most recent patient,

There comes a time in every nurse's career when he/she starts to experience what some folks like to call compassion fatigue. Dictionary.com describes compassion fatigue as " fatigue, emotional distress, or apathy resulting from the constant demands of caring for others..." Now, I know you are probably thinking to yourself that I should find another job or that I need therapy or something, but what I'm here to tell you is that is not the problem. I personally believe compassion fatigue arises when we as healthcare providers are forced to be compassionate towards people who have no desire to help themselves or their situation; who are non-compliant with their medicines or therapies and are just plain rude and nasty people. I do believe that you are truly suffering but I don't believe that you are actually experiencing the pain you are describing to me. I believe your pain stems from a psychological place and cannot be fixed with your constant demands for dilaudid, zofran, percocet, benadryl, and valium. I am not the only one who believes this. Healthcare workers are familiar with manipulation and drug seeking behaviors. Unfortunately for both you and I, the healthcare industry is now so focused on creating the "best patient experience" that we as providers have now become enablers. Even though we know what's in  your best interest, we cannot tell you "no" in fear that we will be reprimanded for not treating your "pain" adequately. You as patients suffer because the root of your actual "pain" is never handled appropriately and when you leave the hospital you will most likely be addicted to narcotics. So if your looking for someone to blame, you can blame the healthcare system. If you looking for someone to fix the problem you are going to have to do it yourself. I advise you to seek the help of a mental health professional not a healthcare professional. We are not skilled in the areas of mental health. Our job is very demanding both physically and emotionally and most of us are not comfortable treating your mental pain with narcotics and sedatives. If all you want is narcotics then it is unnecessary to waste healthcare dollars on tests and procedures to locate your "abdominal" pain that you do not have actually have. I know this probably sounds mean and not very compassionate but its the truth.

Sincerely,

Your Nurse

Family Matters - Part 1

I recently had a situation with a co-worker that I found particularly disturbing yet very eye opening. Let me explain... I recently took care of a man who was dying from end stage renal disease (kidney failure) at the young age of 57. He had 2 daughters ages 21 and 23 and a very large extended family. If you have had any experience working in or being in the ICU, you have probably noticed that the visiting hours are between certain hours, are usually limited to 2 visitors at a time and they never let anyone spend the night in the room. I have never really understood the rationale behind all of these regulations but you know how nursing is, once someone's done it a certain way for a certain time, God forbid you try to change it. I have never been a fan of limiting visiting hours or visitors so I have always just managed my visitors on my own; I usually just pull the curtain so the charge nurse can't see in my room (especially if you have one of those charge nurses who likes to micromanage you); anyway, so I asked my co-worker to come help me pull my patient up in bed. I had allowed 5 visitors in my room because the poor man was dying and they were very polite people so I had no problem with it. As my co-worker entered the room, in a very rude manner, she proceeded to tell my visitors they had to leave the room for privacy purposes, and then when they called her out on her rudeness, she threatened to call security on them!!!! I was absolutely disgusted at her behavior and shortly after had a conversation with her and the charge nurse regarding the situation. What I realized during that discussion is that the culture in the ICU surrounding the importance of family and healing was very negative and in desperate need of change.
I do understand where my co-worker was coming from. I use to work in a place where that mindset was the norm. I believe that culture was created as a result partially because of the patient population and because of learned behavior. Hospitals located in certain neighborhoods bring in a lot of drug overdoses, alcoholics, gang violence, and family drama. I know what its like to not want to deal with someone's personal family drama or have your unit on lock down because a patient's family members are holding you responsible for their loved one's death. I get it. I have had compassion fatigue before. Our job as nurses is emotionally and physically draining. Often times we don't feel respected by our leadership, co-workers or our patients so I can see how we become this way. In 12 hours it is highly unlikely that we will change our patient's family situation or even their physical condition, but what we can change is our mindset and this patient or family's experience.
Each time we fail to treat a patient or their family as individual or apply them to some standard, we lose the ability to be personable. We have to treat each patient situation as its own entity. Here are a few tips:

• Allow your fellow nurses to manage their own visiting hours. If he/she has multiple visitors in his/her room then mind your own business; your co-workers are perfectly capable of managing the situation. 
• If you have to ask a family member to step out of the room so you can turn them or clean them up that is fine, just make sure you say please and thank you and explain your rationale. 
• If you have those family members who like to stare at the monitor and ask a lot of questions, then answer them to the best of your ability. If you don't have time at that moment, then politely say that you can't explain it now but that you will get back to them if you can or give the short version.
• Avoid becoming defensive by becoming curious instead. If someone comes out to notify you that they think that there is a problem with their loved one's IV simply say "really?" "let me take a look at it". You can seriously use this response for everything. 
• If a family member wants to cover up their loved one and this patient has a fever, it is okay to cover them with a sheet, I promise you it's not going to hurt anything. Most people are pretty modest. 
• If someone is dying then do everything you can to accommodate this family. You can single handedly change the way this patient and their family experiences death. I know in healthcare we have become numb to death, but just so you know this is not normal, the rest of the world still thinks its a big deal. 
• If you are dealing with a nurse who you notice does not provide respect and decency to patient's family members, then either bring it up to them or tell your manager. I think in most cases that these nurses aren't even aware that they are doing it.
• Do your best to put yourself in this family member's shoes. Being in the hospital is difficult for both patients and families. How would you expect your mother, father, son or daughter to be treated?

The old mindset in the ICU is that we are too busy saving people's lives to stop and answer questions or get you a warm blanket, but the fact of the matter is that providing a quality patient and family experience and treating people with respect and common decency  is much more powerful than medicine alone. 

How to Easily Please your Patients and their Family

Whether we like it or not healthcare has now become a customer service industry. The days of kicking visitors out for "quiet time" and expecting patients to just do what you tell them and don't ask any questions are over. Healthcare is shifting to a more collaborative, holistic approach to taking care of patients with the ultimate goal being patient satisfaction. I hear many nurses, especially the seasoned ones, complaining about this approach to patient care and I can understand their point, a little. The old way of thinking, at least in the ICU, is that nurses are here to save patient's lives not pamper them; the hospital is not a hotel. While I do believe there are situations when patients are so gravely ill that really the main focus is on life sustaining treatment, the reality of the situation is that many of the people we care for are just in need of close monitoring. In the ICU especially, taking care of the family members is often the most challenging part of the job. Many patient's family members have been taking care of their loved ones themselves for many years; they can be protective and particular about their care. Watching someone you love suffer in both physical and emotional pain can be overwhelming for everybody, including healthcare workers. I think as healthcare providers we can be numb to people's suffering. Our job is demanding emotionally and physically. Spending 12 hours with someone who has inconsolable suffering is draining. Through my experiences in the ever changing world of healthcare and customer service, I have discovered some patient satisfaction practices that have made my work life a lot easier.

• Utilize the white board - As an ICU nurse I use to think to myself  "why am I going to fill this out when the patient is on a ventilator or is too confused to even know they are in the hospital?" The fact of the matter is that patient's family members read that board too. Something as simple as writing your name and the general goals for your shift decrease the amount of questions significantly. I also like to form a pain management plan for patients during my first assessment and write down their pain medicine schedule on the board. For those of you who are in administration, the only time I feel like it is pointless to write on that board is when it is hidden in some random corner somewhere where no one can see it; so do us all a favor and move the boards into a more appropriate location. 
• Don't take it personal - Many family members can come off as aggressive or rude. Sometimes you feel that they are questioning whether or not you are competent enough to care for their loved one. Sometimes they are just plain crazy. The best advice I can give you is to not take it personal. These people scared, overwhelmed, tired and stressed out. When they are bombarding you with questions or questioning your care, the best thing to do to prevent yourself from getting defensive is to become curious. When a family member tells you the foley bag is full and needs to be emptied (when it fact it just needs to be tipped) all you have to do is say "really?, let me take a look"; and then you do some education "oh, it drains over into the bag, but thanks for letting me know." There are cases when patients or family members are really crazy and in this case you ask them to leave politely and call security if need be. 
• It's all about the look - Nobody wants to see blood stains on their bed sheets or gown. In the real world, outside the hospital, that's just plain gross. Keep your patients and their rooms tidy. Shaving someone and combing there hair can make a patient both feel better and look better. Try to keep them looking comfortable in the bed. I know this is impossible for some people, but do your best. 
• Focus on the small things - Patient's family members tend to focus on the small things. This is their way of participating in their loved one's care. Just because your patient has a temp of 102 doesn't mean that you can't place a simple sheet over them. Most of the world is fairly modest when it comes to exposing their body parts. If it makes the family happy, cover them with a sheet. If you have family members that like to stare at the monitor, you can do a quick in-service as to what the numbers mean, what you are looking for and reassure them that you can see the monitors at the nurse's station. 
• Education - Take the time to explain what you are doing and provide rationale to patients and family members before  you do something to them. Explaining to a patient or family member the importance of re-positioning to prevent pressure sores will most likely encourage them to want to participate in their care. 

These are just a few suggestions to make your shift a little easier. The nursing profession is so demanding and everyday I feel like we are being told to do more. If you can find a routine or practices to make you work life easier, it will make you happier; and when nurses are happier, patients are happier. The fact of the matter is that patient satisfaction does affect our profession. Patient's have a choice on which hospital they want to go to. If patients don't want to come to your hospital then guess what, you will be out of a job. 

Suffering and Self Exploration

 I recently attended an opioid training class and heard a statistic that I found interesting; apparently, the number of people who die from accidental drug overdoses is equal to the number of people who die in car accidents. I wasn't shocked by this statistic; every time I turn around I'm taking care of some poor soul who took too many pills. Regardless of the reasoning behind all this drug abuse, whether it be emotional or physical pain, I believe the urge to anesthetize our suffering has become an epidemic among the general population.
According to James Davies, Author of The Importance of Suffering, a negative view of suffering, which labeled all suffering as harmful and should be avoided, arose in the 1980's. It was then that the medical community decided that emotional suffering, like physical suffering, comes from a biological process and should be treated the same as physical suffering; with medications. And so it began, whenever you have a problem, you can fix it with a pill. Now we are coming to a point in medicine that whenever you have a problem we can fix it with surgery. The practice of treating patients solely with medication or surgery has devalued the importance of exploring any of the other possible causes of people's suffering, such as psychosocial, spiritual and other implications of human distress. I believe this lack of exploration and accountability has enabled people completely. What bothers me the most is that the healthcare system benefits financially from the exploitation of people's suffering. According to James Davies "when individuals are unable to understand and manage their own suffering, they become vulnerable to certain authorities who claim to have the knowledge and expertise to help" (pg 74); making it easier for hospitals to market their "new and improved" surgical techniques to patients with the promise of taking all their suffering away. I am not saying that all patients can solve their own problems and should never rely on the expertise of their physician, but I do think the majority of the patient's I take care of can benefit from a little suffering and self exploration.
Some of you may think, "this crazy nurse just lets people rile in pain all night." I bet some of my patients would agree with you. There comes a point in my job where I have to decide whether or not the pain medicine I give you is going to benefit or harm you. Let me share with you the factors I include in my pain assessment and what you should expect when you are having pain in the hospital.

1. For a majority of the patient population I can tell you now that we cannot take away all of your pain. There comes a time in the hospital when someone will ask you what level of pain is tolerable for you from 0-10, with 10 being the worst you have ever felt. If you tell me you cannot tolerate absolutely any pain (meaning your tolerance will be a 0) than I will most likely tell you this is unrealistic. With all surgical procedures, acute illnesses and well life in general there is going to be some kind of pain. The best thing for you to do is come up with a plan, with the help of your doctor and nurse, on how you are going to deal with this pain. 
2. If you tell me you are experiencing 10/10 pain but you cannot keep your eyes open for more than 10 seconds or hold a conversation with me, I will not give you more pain medicine. This my friends is for your own safety. If I were to give you pain meds in this state, there is a good chance you might end up a statistic. You see, most pain medications cause your breathing to slow down. In some instances your breathing can stop, leading to a respiratory arrest and possibly death. At this point we would have to find an alternative like hot/cold packs, re positioning, dimming the lights, etc...
3. If you are a person who has chronic pain and is dependent on multiple pain meds at home, this does not change because you are in the hospital. Many times you are experiencing what we like to call acute on chronic pain which means that you now have something else causing you pain on top of what has already been ailing you. It is especially important that I know your tolerable pain level and what you do at home to manage your pain. If you are taking pain pills every hour I can tell you now that we cannot do that for you in the hospital; we have to follow guidelines. We will do our best to take care of your acute pain while managing your chronic pain but we cannot take it all away. 
4. If you think that sleeping your hospital stay away will make your life easier, you are wrong. Just like in life, anesthetizing all your suffering only leads to what we like to call secondary suffering. If you are so sedated that you cannot get up and walk around, feed yourself, take deep breaths, go to the bathroom and so on..., there will be other complications that come around. A lot of patients develop pneumonia from over sedation, muscle weakness, difficulty swallowing, and prolonged hospital stays. 
5. We do not want our patients to have a bad experience in the hospital. We will do our best to make you feel comfortable and not afraid. Everything we do whether you like it or not is for your own safety. It is for your own safety that we have reasonable expectations surrounding pain management. 

Allowing yourself to experience pain can provide you with insight that could possibly change your life. Chest pain associated with a heart attack may be a reminder to yourself to put down that cigarette; the pain of a kidney stone may remind you to drink more water; withdrawing from alcohol (if you remember it) may prevent that next drink. Suffering provides us with an opportunity to change our lives. Depression forces us to want to be alone, to over analyze, to question ourselves. It provides us with the opportunity to change our situation. Pain is a sign from our body that something is wrong. Maybe we need to slow down and take it easy, maybe we are eating food that is causing us discomfort, maybe our lifestyle choices such as smoking or drinking are causing us emotional and physical pain. Whatever ails you, there is a reason. Instead of anesthetizing the pain with medications, alcohol or drugs, dig deep and ask yourself "why am I feeling this way." We have the answers to most of our questions; we have intuition; we know ourselves better than anyone else. Instead of turning to drugs, alcohol or your doctor, try turning to yourself.

Living above the Line

Is it just me or did nursing school make anyone else feel like they had to be a saint upon graduation? Maybe it's because I went to a catholic university ... I don't know. Regardless, the more and more I do this job the less and less I feel like a saint. I recently got report from someone telling me about my 35 year old patient who is an alcoholic and is dying from end stage liver disease. Now, I agree that this is a sad case. I'm sure there was something in his life that he couldn't handle and he turned to the bottle to make himself feel better; I get it; but in reality the first thought that came to my mind when she told me this was "well this is what happens when you drink too much." I know to most, especially for those not in the medical field, I probably sound like a cold hearted you know what, and that's okay; I was recently called that by someone so it's not a big shocker; I think compassion fatigue is what I'm suffering from (that sounds a bit nicer than cold hearted you know what); or maybe I am just being a realist.

I once worked with this wonderful nurse at St. Anthony North hospital in Colorado named Marsha Parker. She was an ex-army nurse, head of the quality department and one of my many mentors at that hospital. She introduced me to a term "living above the line." Living above the line means you take responsibility for your own life and you stop blaming things outside yourself for your situation. I usually refer to people who are living "below the line" as victims. Below the line thinking is when you are consumed with the problems, drama, and excuses for why something can never get done. There is always a problem, even with the simplest tasks such as picking up groceries or getting your mail. You are continuously consumed with the “why” something happened rather than “what” can be done to move forward. There’s a comfort with staying where you are, and you’ve conditioned yourself to offer excuses instead of overcome them. It’s a mindset. Below the Line living leaves your frustrated, angry, unsatisfied, defeated, fearful, defensive, stressed, resentful, and anxious much of the time. People who live below the line are constantly blaming others for their behaviors as well as their suffering. Sound familiar?

I think this type of behavior is very common in the world of medicine. Many of our patients are in the hospital as a direct result of their own bad behaviors. What bothers me the most about these patients is that most of them seem shocked that they are sick; like no one ever told them that drinking, smoking and eating poorly is bad for you. Healthcare has now become a customer service industry where the "customer is always right." You can't say anything to a patient that might make them upset in fear that they might choose another hospital to go to; I once got in trouble for telling a woman her breathing problems were related to her obesity. How can we help people get better if we can't hold them accountable for their behaviors. I know there is a time and a place to bring up accountability and often times the hospital can be a challenging place to do so without getting in trouble. So I choose to bring it up here and now.  Here are a few examples of preventable behaviors that often lead to a whole lot of suffering:

• Smoking cigarettes will eventually lead to some form of lung disease. When you get older you will most likely experience some shortness of breath with activity or at rest, will require frequent visits to the hospital where we will most likely either put a breathing tube in your lungs or place you on a breathing mask for days on end. You will most likely be very anxious and feel like you are suffocating because your lungs are no longer functioning and there is nothing we can do about it. The only thing you can do is quit smoking before this happens. 
• Drinking alcohol in excess for many many years will eventually lead to liver failure. Your eyes and skin will turn yellow, your belly will fill up with fluid, your kidneys will shut down, you will become very confused, lethargic and eventually unconscious. There is nothing we can do for you at this time. You are not a liver transplant candidate. Seek help early before its too late.
• Eating in excess to the point of morbid obesity. You will most likely develop diabetes, heart disease, sleep apnea and possibly cancer. You will have many skin issues and have a hard time healing when you get sick. Food is an addiction, get help.
• Non-compliance: If you are diabetic and you don't watch what you eat and take your medications appropriately, you can expect that dialysis, blindness, neuropathy, loss of limb, foot ulcers and a heart attack will be in your future. 
• Being lazy: Exercising is key in preventing a whole host of chronic diseases. Get off the couch and go for a walk.

These are just a few of the many bad behaviors I see that can lead to suffering. Fixing these behaviors and living above the line requires hard work but that's just a part of life. You cannot take the easy road all the time. Using alcohol or drugs to avoid suffering will only lead to more. It's time to stop making excuses and start taking responsibility for your actions. If something in your life isn't going the way you want it to then change it.  If you know your fate is being a one legged man spending three days a week on a dialysis machine and that doesn't sound appealing to you, then do something about it before its too late. 

Acidosis and Osteoporosis

Osteoporosis, alongside hot flashes, is every menopausal, skinny, white woman's nightmare. According to the National Osteoporosis foundation, osteoporosis is responsible for 2 million bone breaks a year. For most of us in the biz of healthcare we know that breaking a hip, in most cases, is a one way ticket into a nursing home (if you are lucky enough to actually leave the hospital).  According to the CDC, in 2010 there were 258,000 hospital admissions for hip fractures among people aged 65 and older and one out of five of these patients died within a year of their injury. If you weren't scared of breaking a hip before, I hope you are now; this, my friends, is a serious issue. We usually think of osteoporosis as an old person's disease but what we don't realize is that the process of building strong bones and preventing osteoporosis is a continuous cycle that starts when we are children. 
I recently had my annual physical and was pleasantly surprised that my physician addressed osteoporosis prevention with me. Now, I appreciate the time and effort she put in explaining to me the importance of calcium and exercise in osteoporosis prevention but I felt like the information she provided was seriously lacking in very important areas. Preventing osteoporosis is not as simple as drinking milk and exercising; if it was, the United states alongside the United Kingdom, Finland and Sweden, would not have the highest rates of Osteoporosis in the world. The dairy industry has spent millions of dollars convincing the general population that "milk does the body good." The dairy industry has so much influence that the new food pyramid/plate still has a glass of milk on it. I can tell you that after receiving my most recent certification in holistic nutrition and reading numerous books on bone health, that milk actually has the exact opposite effect on the body that it claims to have. According to Vivian Goldschmidt, founder of the Save our Bones Program (http://saveourbones.com/osteoporosis-milk-myth), milk creates an acidotic state in the body therefore, depleting calcium from the bones.
As an ICU nurse I have come to appreciate the body's need to maintain an acid base balance. Acid base disturbances can cause a multitude of symptoms including headache, dizziness, irritability, nausea, confusion, gait disturbances and sometimes death. The body will do whatever it takes to keep the pH balance in your blood between 7.35 and 7.45. In only a few circumstances do people ever become alkalotic (pH above 7.45) so for the purpose of this blog I am going to focus on the acidotic state. 
In an acidotic state the body will increase respirations to remove CO2 from the body, the kidneys will secrete bicarbonate to buffer the blood as well as excrete urine to remove acids, and the bones will release calcium and other buffering minerals into the bloodstream;  so, it would make sense that being in a chronically acidotic state would cause osteoporosis since the bones would have to be continuously releasing calcium into the bloodstream to buffer the blood. Now that we have that down lets talk about what foods/substances can push the body into an acidotic state. This website http://www.vegan-raw-diet.com/alkalinefoods.html has a great list of acidic/alkaline foods. They recommend eating 60% alkaline foods and 40% acid forming foods to keep you body in balance. The general idea is to increase the amount of fruits, vegetables and whole grains and decrease the amount of meat and dairy in your diet. I'm not saying turn yourself into a vegan but if you can at least entertain the idea of "Meatless Mondays," you might actually save yourself from a broken bone and maybe even a heart attack.