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Primary Nursing tips November 1, 2009

Posted by mariemanthey in Primary Nursing, Staff Nurses.
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Logistics of assignments complicate Primary Nursing so much that many people feel it is impossible in today’s health care system.

I say Nonsense!   Keep it simple and it works!

Pragmatic not Perfect!

Short term patients need short term goals!

Do nothing that violates your common sense!

Decide in favor of the patient and it will be in favor of the nursing!

Nine times out of ten the problem is either unskilled leadership at the NM level or unhealthy interpersonal relationships among the staff. Both of those need to be solved Then let the staff decide the logistics — of both their schedules and assignment continuity.  

It works!  And patients need it more today than ever before.


Is Polite “Doing For” Really Enough? January 17, 2009

Posted by mariemanthey in Professional Practice, Relationship-Based Care, Relationships, Staff Nurses.
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One of the consultants at Creative Healthcare Management recently sent me this description, written while her daughter was receiving care at a major medical center in the Midwest. My question to readers is this: if you see yourself in this description, what can you do to “be with” rather than just “do for” your patients?  Or does anyone want to explain why “doing for” is really enough? Responses are welcome.

“Care has been fine, but not extraordinary.  They  received Magnet designation in 2007 and have a great deal of pride.  Everyone asks each time they leave the room if there is anything else we need — and they have clearly received customer service training (AIDET).  The manager just visited our room and was gracious and emphasizing that we let them know if there is anything they can do.  The trouble is, they are doing … But there is no “curiosity”, no whole picture perspective — when asked the nurses rarely know the plan — I rarely see a therapeutic process; the nurse comes in to give meds, check if there is anything needed.  So very nice, polite — but detached.  I found myself charting my perspective using the boundary diagram from my article in the field guide on boundaries for the therapeutic relationship. Underinvolvement is the main descriptor I would use.

We have had some lovely exceptions. The pharmacist, who we know from the transplant team spent 20 minutes with us yesterday making sure that we had all questions answered and providing some background information and questions. A physician sat at eye level and began by asking Alicia about her and what this means in her life right now.  She was able to talk about school, and it went on from there.  He was extremely encouraging — reminding us that it has always been the case that my daughter would outlive the life of her kidney, and that we will take each challenge as it comes.  We do not have the biopsy results yet, but if it is early rejection we are dealing with, that can be treated and the kidney can continue to serve her.

I try to stay clear and unemotional about the lack of professional consciousness I see in so many nurses.  I feel so sad, because when they only focus on the things they are doing, they lose sight of the human being and the power of their care and they lose the amazing satisfaction that would come from a connection.  I am clear that it would take no more time to connect and involve the patient than to come in and out doing for the patient.  I believe the nurses on this unit like their work, and that transplant nursing would be extraordinarily satisfying.  So, the nursing care is fine.  The question is, is that enough?  I have nothing I would complain about, and I believe most patients would say the care was very good because the staff is responsive.  My daughter asked why so many people (nurse,  physician, nurse practitioner) give her the same information as though she is hearing it for the first time.  Not one nurse has asked Alicia about herself or what this hospitalization means to her — what she might be worrying about — what is most important to her.  This morning as I walked for my coffee I noticed no one looked up anywhere through the hall ways to the cafe, so I began initiating and spoke to people even when they were looking at the ground.  I got responses in return and I am teaching my daughter how to be the initiator of relationships so that she can be seen and receive what she needs.  I have also had to work with her to monitor her responses (she got rather hysterical when experiencing pain and not feeling heard by the nurse — who I understand called her a whiner– I was out of the room at the time) — I followed up with the nurse and worked to help her feel safe and less defensive, we came up with an approach to Alicia’s pain and by the end of the day it was managed.  I had to intervene, though because I could see that the nurse was irritated with her and I want Alicia to learn how to care for relationships so she does not get written off.  She will need to be an expert as she will be needing care all of her life. “

Nurses Have an Amazing Capacity To Do More! March 24, 2006

Posted by manthey in Primary Nursing, Staff Nurses, Staffing.
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I know if I said this in a speech before an audience of nurses, many would get angry, and some would probably walk out. And yet, it is a statement I believe to be true. Not all nurses. Not in all work situations. Not all the time.

But over my many years in the profession, I have seen the restraints that handicap our role expansion and have envisioned the contribution nurses could make to the health care of society if those restraints were removed. The realities I call restraints are both internal and external. Some are imposed by regulations designed to protect the job security of others, as well as the job security of nurses. Some are in place because of historical precedents not yet dissolved … precedents like inadequate education, cost constraints, physician-nurses role delineations disputes, and the sexual discrimination still somewhat prevalent in today’s society. Some of these are so big, and are kept in place by such powerful forces, they seem insurmountable.

Others are restraints of our own making. These include a pervasive reluctance/fear to accept responsibility for ourselves, our practice and our interpersonal relationships. They include a “within the profession” reluctance to assert the right of control over nursing practice by virtue or our license. They include a willingness to work in environments that are dysfunctional … without either fixing the problem or leaving the work setting. They include an incredible tolerance for ‘within the profession’ disputes about solvable problems like entry level educational standards and proper utilization of support staff (including Lens). Enormous amounts of energy is dissipated at the highest levels of professional development on issues that require strategic and tactical decision making among various interest groups within the profession. Decisive action in these areas, (while probably not agreed to universally) would still have the power to restore energy to more productive uses.

What do I envision? For openers … the lack of continuity at the system level that patients suffer from could be solved by developing procedures for call-backs to patients homes. Not all patients, not all the time, but it a responsible nurse can decide whether to do so or not. I can envision a role for RNs that includes time for “‘looking at the big picture” and exercising real coordination/cooperation among specialties in highly complex situations. This can be done by providing appropriate technical support staff. I can envision nurses partnering with physicians (or other primary providers) collaborating in decision making, along with empowering patients to participate/own health care decisions. I can envision nurses creating support structures for non-nurse care providers that both educates them in the techniques of patient care and also supports them emotionally

I am a partner in a company that has software for healthy people to track their own health care data and set goals under the guidance of an advanced practice nurse. The employees enrolled in our program have significantly fewer major health problems, and cost their employer much less for health care.

We are so bogged down in task performance, so diminished by our sense of self-worth and so willing to abdicate responsibility for what we are licensed to do that we haven’t taken the time to lift our eyes, envision a new future and and learn how to play together to create a world here nurses are having a major impact on the health of society and are manifesting health lives ourselves!

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