Is Perception Everything When Caregivers Lack Clinical Skills?

Not long ago, there was a patient at the hospital who was admitted for pneumonia. During the course of hospitalization this patient attempted to get to the bathroom without assistance. She fell. The fall resulted in a hip fracture. She was taken to surgery two days later for the repair. The surgery was successful and the patient was returned to the original floor. Everything seemed to be going well when suddenly she became unresponsive. She coded and was resuscitated but it was unsuccessful. The patient died. A root cause analysis was done over this incident pointing to the fall as the problem and the decision was made to mandate the hourly patient round. Nurses or patient care technicians (PCTs) are to enter the patient room, go over a scripted checklist with the patient that includes pain, elimination needs, and position changes, indicate when they will return, document the round and leave the room. The hourly round is supposed to reduce patient falls, prevent skin breakdown, and cut down on the patient calls between rounds. Most nurses are very busy during their day. They do not have adequate time to round on all their patients and get the rest of their jobs done. This results in skipping hourly rounding while documenting creatively at the end of the day. Managers, in an effort to make sure that all patients are seen, then mandated that PCTs round hourly instead of alternating hours between nurse and PCT as was originally intended. According to our Studer coaches, patients will believe because of the hourly round that we are giving them excellent care if we appear in the room every hour and go over this checklist with them. Do they really?

I saw a TED talk the other evening about perception. “Perception is everything” was the theme. In my field, health care, we apparently agree. Perception is very important. A patient’s perception can mean the difference between getting well and going home or dying in the hospital. According to research done by someone, patients who perceive they are getting excellent care, regardless of the actual quality of the care, are more likely to have a positive outcome than patients who perceive their care is bad (again, despite the actual quality of the care). Do you believe this? I have trouble with it. I have known some nurses who spent hours in the room with the patient, talking, counseling, bathing and documenting but when it came to recognizing clinical deterioration, they were completely clueless. I remember when I first started in this business, nurses could be absolute holy terrors and nothing would ever be said because they were excellent clinicians. They might have the bedside personality of pit vipers but they brought their patients back from the jaws of death and the patients were grateful for it. Usually these were the ICU or ER nurses. The hard core battle axes that stared death in the face and you just knew that death itself was a little intimidated. Was perception as important then as it is now? Or perhaps patients perceived that care would be above par when the nurse was no nonsense and a bit brusk. I don’t think so, however. I believe that at some point in the past 20 years things have changed drastically.

Now don’t get me wrong. I think that it’s important to offer quality and service to patients. Their caregivers should be empathetic and friendly. We see patients on the worst days of their lives. They don’t deserve to be treated like widgets moved through an assembly line. They don’t deserve harsh words or rough hands. They deserve to be taken care of, pampered a little, reassured and comforted when they are frightened. From what I gather, talking to people who’ve been in the patient position over the past sixty to eighty years, nurses were caring. They might have been no nonsense but you could tell that they cared through their actions. That does not seem to be the case anymore, according to these interviewees.

My point is that perception has not always been the be-all, end-all of reality. At least, I didn’t think so. I’ve always believed that intention was a valid element on which to base judgment. We have probably all seen the quote “the smallest act of kindness is worth more than the grandest intention” (Oscar Wilde).  However, I think that action without intention is careless. There is no act of kindness without the intention of kindness behind it. We hawk perception as the cure but is it really? Is it not much more likely that the real problem is that we are lacking caregivers with the clinical skills necessary to offer excellent patient care? This includes the softer clinical skills of empathy, compassion, communication, and the hard won character traits of accountability, integrity and contribution. So rather than focusing on perception as the way to fix a problem with clinical skill, why not address the intention behind the actions. If a nurse does not intend to give excellent care, then she shouldn’t be in the field. No amount of pretense is going to make her give excellent care. It may fool the patients but probably not for long. Someone who is pretending to care won’t be able to keep up the pretense in the face of patient demands where someone who actually cares will rise to the challenge. Conversely, the nurse who truly cares about the patient needs the opportunity to learn and grow in her craft.

I’m the first to admit, it’s not an easy fix. This demands a look into the way nursing is taught. Nursing is not a good job for everyone. It is tough. Not only is there a lot to learn about body systems and disease processes but there are ways of thinking about problems that are absolutely vital for the nurse. Critical thinking is the ability to use the body of knowledge we possess as nurses, along with the most current research, to approach a problem and develop a solution without becoming emotional or panicking. For the new nurse, it takes almost five years to begin to think critically about patient situations. Up until that time, the new nurse is just learning to take care of the tasks that consume her day. It takes that long for her to become comfortable enough with the everyday tasks that she can learn to see the bigger picture. Perhaps by incorporating more clinical time into the nursing program, new nurses would begin a faster transition to critical thinking proficiency.

I believe that instructors need to weed out nurses who do not have the necessary attitude or character. While this might take some specific parameters and attention to detail, I believe it is possible to do. In Medical School, students compete against each other, not only with grades but with procedures. Med schools weed out the students who do not have the grades or the resilience for the program. Nursing programs should do the same. If the student nurse is not at the top of her class she will not be offered a good internship program. If hospitals commit to recruiting only the best and offering nursing internships that would give the new graduate clinical practice and mentoring we might end up with a better quality nursing student and graduate nurse. Instructors could make nursing students compete for procedures. My experience with students on the floor is that they will do everything in their power to avoid work. If they have to be checked off on a number of procedures it stands to reason that they would know how to do some of these procedures when they graduate. If they don’t get the procedures then they don’t graduate and the school weeds outs yet another student who did not want it badly enough. We got away from the diploma schools but maybe that was a bad idea. Could we not combine the book work of the BSN program with the clinical labs of the diploma school? The hospitals that participated would have the added bonus of free student labor and a skilled labor pool from which to choose the best and brightest. It might be worth considering.

I believe there is an urgent need to fix these issues before it’s too late. When the last of my generation is retired, the only ones who will be left are the nurses who are graduating now. The nurses who don’t have the first clue about critical thinking will be in charge of the ICU. The nurses who consider Facebook a good place to complain about their patients will be taking care of you and me. The nurse who thought herself above giving her patient the bedpan, causing a little old lady to climb out of bed over the rails and fall, fracturing a hip, will possibly be a manager or director. In my opinion, that would be a damn shame.


Prophylactic Antivirals

I was at lunch with some coworkers discussing the rash of flu cases popping up in our small town. Surprisingly, or perhaps not, these people have all had the flu vaccine so contracting the flu has been worrisome for them. In most cases, upon seeking medical assistance, they have been given an antiviral medication (Tamiflu). I’m distressed by the readiness of doctors to prescribe this drug. Before the antiviral was available, what did they always say. Get plenty of rest, drink lots of liquids, take Tylenol for aches and pains and it will run it’s course in 10-14 days. This may not be what people want to hear when they go to the doctor but seriously it will work. Unless the patient is in a high risk category, the antiviral isn’t recommended by the CDC. I just read this last night. So why are doctors giving the prescription? I personally think it’s because we are putting way too much emphasis on “customer service” and not enough on sound medical advice. If I can go to my doctor and tell her what I want and she gives it to me, no questions asked, I’m not really getting her expertise. She’s not doing me any favors by giving me prescriptions without making sure I really need them. I know some patients expect the doctors to have a good bedside manner (which is code for do exactly what I tell them) and I’ve met patients who don’t feel the visit has been worthwhile unless they get a prescription. Put those patients together with a reimbursement system that dispenses payment based on patient satisfaction and you get doctors who will hand out prescriptions that aren’t needed.

Back to the flu, I’m even more distressed by hearing that doctors are giving this out prophylactically. A husband has the flu and they give the antiviral to him and his wife, even though she has no symptoms. The flu virus can mutate, people! By giving antivirals willy-nilly, we are going to create a super flu that nothing will kill. Then, my friends, we are   in for some serious trouble. This isn’t new information. Everyone knows that the prevalence of antibiotics is responsible for creating the “superbugs” like VRE (Vancomycin Resistant Enterococcus) or MRSA (Methecillan Resistant Stapholococcus Aureus). The same is true of viruses. Check out the CDC website for more on this. Thankfully Tamiflu is still a drug that will kill the current flu strain. But, if doctors continue to give unnecessary prescriptions, it’s going to bite all of us in the butt.

At least that’s this nurse’s opinion!

Let me know what you think!

Good Intentions

It’s been seven months since I first posted on this website. I had planned to share my thoughts and feelings about the situation I’d found myself in and hopefully gain some insight along the way. So much for that!  The multigenerational family concept was too much for us. Mom and Dad have gone to live in a retirement community much more suited to their stage of life and I am moving back to my comfy little house (as soon as my tenants vacate). It’s what we should have done in the first place. We just weren’t quite ready to admit the need.

I was really happy to have my living space to myself again. I’m not a social person. After a long day of listening to other people’s drama and answering questions, I don’t want to come home to do more of the same. So it’s been a treat to stroll through this empty house, hearing nothing but the gentle tapping of cat claws on the hardwood and the melodious baying of my neurotic husky. Seriously, it’s music to my ears. Home is once again a sanctuary where I can find peace and rest.

However, I can’t find my mail. My dad checked the “whole family” box on the address change form and now my mail is going to the retirement center. It’s a small price to pay and a problem that I can easily resolve so all is still well.

However, I wondered what I would blog about now. Now that the people who were likely to cause me to become clinically insane are living elsewhere. Ha ha. Not to worry, there are others who are willing and able (and just a little bit desperate, I’ve discovered) to take my parents place.

My first weekend alone had come and gone and I was getting ready to go to work in super slow motion. I did the responsible thing and let my boss know with a friendly email. She said “cool” and went on about her day. She didn’t share the news because, well, why would she? After all, I’m an adult who’s capable of coming to work on my own, My coworkers, a wonderful group of concerned and loving women, went into major “where’s Nancy” panic and started calling my phone, and when I didn’t answer, friends who live in my neighborhood. As I was running late, I’d left home without my  home cell and my work cell. Whoops. So needless to say, by the time I got to work, there were anxious women running up and down the hall, imagining the worst and trying to formulate a plan to find me. I’m a little relieved I wasn’t actually missing. I don’t think they would have reached the stage where someone actually fills out a missing person report. I believe they were enjoying the frantic running up and down the hallway. I did notice as I straggled in that everyone had a cup of coffee and seemed reluctant to leave the hallway and settle in to work. In fact, several more times during the day, they gathered in the hallway to recall the exciting events of the morning. My boss thought it was funny. “Guess you’ll have to CC the rest of the office on any future emails” she said as she popped into my office to laugh. I haven’t lost two parents, I’ve gained four more. Aaauugghh!

My journey through madness continues.

The Chickens Came Home!!

Have you heard the saying “the chickens have come home to roost”? This is supposed to signify a karmic state of getting what you deserve. I suppose that I do deserve this. For years I’ve taunted my brother with “I’d never let Mom and Dad go to a nursing home”. I even believed it to an extent. I just never thought I’d have to take care of them. But now, the chickens have indeed, come home to roost. I’ve left my comfortable little house and moved in with my elderly parents to help them during their golden years. My 80-year old mother has Alzheimer’s Disease which creates a burden on my 84-year old father. So I’m here to save the day with two advance practice nursing degrees and my slightly warped outlook on elder care.

In order to accomodate my furry family (two dogs and five cats) my folks sold their practical townhouse and moved to a large single family house in the suburbs. Complete with a large yard, this house has quickly become the focus of my father’s attention. He spends as much time outside in the yard as he can. Thankfully my mother is content to sit in a sunny spot and re-read her favorite book. I feel guilty that I made them leave the townhouse where all the outside work was done courtesy of the HMA. Because of the demands of my job, I don’t have as much time to spend in the yard or with my beloved animals or with my folks. I work, come home, eat and sleep only to begin again the next day. By the weekend I’m exhausted and barely crawling through necessary chores. I wonder if my folks have doubts about me being able to help them. I know I do.

I have to admit that I resent my brother for his ability to walk away from our parents and not look back. He obviously isn’t concerned about the precedent that he’s setting with his own daughter. Perhaps someday, he’ll understand the significance of chickens coming home. However, that can’t be my concern anymore. I’ve made my bed (another deplorable cliche) and I have to live with it. I insisted that the nursing home wasn’t the place for MY parents. I’m hoping that with this scribbling account of my new life as a caregiver, I’ll gain insight into my own heart and mind as well as spark some comments, advice, prayers, and good thoughts from those that happen across my musings.


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