At last night’s (May 15) Salon, a Clinical Nurse Specialist told of an incident he was involved in yesterday, when another staff member asked him to “make them stop fighting”. The ‘them’ was a Nurse Practitioner and a Medical Resident. The ‘fight’ was a role conflict that surfaced during a patient discharge. You can guess….the resident said the practitioner was practicing medicine and the practitioner said the resident…..well, you can fill in the blanks. This ‘fight’ delayed the patient’s discharge by 5 hours!

This was one of the many experiences the 20+ guests brought to last nights discussion. And this particular incident led us into an interesting and informative discussion of role conflicts…what they mean and how to deal with them, and how to avoid them.

Two of the guests graduated just the day before our gathering and are interested in how to enter the work world in a healthy way. One guest was a nurse leader from Kenya, Africa, whose issues mirror ours in so many ways …and yet the system and the culture is so different. She spoke of the problem of nurses not being confident and many people talked about ways to acquire inner strength as a nurse.

A topic brought up almost every month is the issue of ‘entry level’ into practice….as well as new roles being created in new education programs. AD’s,BSN’s, MN, CNS, CNL, DNP, Phd,…some people’s confusion was eliminated….(others learned about new developments) and the discussion ultimately focused on the many complexities we face, and also on how do we as a profession stay united in purpose and integrated in message as we continue to evolve. As always, the contribution of individuals reflects both the uncertainty and pain of change, but also the hope and belief that whatever our preparation….our relationships with patients, with ourselves and each other is the key to honoring our covenant with society.

I encourage everyone reading this to first of all, add your 2 cents worth to the discussion. I love to read your comments and will respond. Secondly, I invite all readers to join me in a campaign to replicate these Salons. I am convinced that nurses desperately need a safe place to talk both about the issues we face in daily practice, as well as the enormous complexities of the systems we work in…..as well as the complexities of providing appropriate care in the broken health care system.

I will help anyone interested in getting one started. I have a new written description that summarizes my experience hosting one for seven years. The healing that occurs when these deep connections are made about important experiences is truly profound. And it is very easy to have a salon….just ask and I will tell you how easily it can be done.

The wonderful thing about these gatherings is that there is no agenda, no minutes and no action steps! No carry-over from one to another. Each one is a total event in itself. We just come together in a safe environment, agree to professional confidentiality….and use the ‘Socrates Cafe’ format to handle the discussion. The result is hope and healing.

My goal now is to have websites throughout the US where a nurse can go to see the Salons scheduled in his/her city/town….for the month! And can pick the one to go to based on their own schedule and the events location.

Several of us have started talking about how to do this ….and frankly, we don’t have a road-map…..but then,we didn’t have a ‘road-map’ for Primary Nursing…back in the late sixties, and look how that idea spread from one unit at the U of M to a world-wide movement! So…I know this one can too.

Last nights Salon was another wonderful experience.    We touched on a variety of subjects from unhealthy work groups -to the challenges of ethnic differences in end-of-life care-to age disparities in nursing practice and their effect on workplace dynamics.

For example, that last item….old-timers complaining that  new nurses spend too much time on the computer and not enough with patients …..and new nurses complaining about seasoned nurses being too judgmental about patient behaviors and values that are different than the nurses.   These comments yielded a rich and meaningful conversation that ended with a strong appreciation of connection between the older and younger nurses in the room.

Another rich theme of the night was how do nurses handle the stresses and strong feelings that occur on the job (ie death of a beloved patient, family disputes re. end of life that result in patient suffering, etc ) off duty?   Do our families really want to know about these issues?    Consensus was “No”….and the problem of no one to talk to about this and no time at work to process emotions was a really good and helpful conversation.

Actually for most people here, these Salons are providing this kind of an opportunity to process their work experiences in a supportive and healthy way.    The check-out always yields comments about hope for the future, pride in the profession, and  personal validation of experiences.

The group at this Salon was another interesting mixture of different ages: from a couple of student nurses, to several new as well as senior staff nurses, Nurse Managers, an educator, a retired physician and a couple of Clinical nurse  specialists.   The discussion eventually focussed on pressures created by the health care system and the relationship issues present in current practice settings.   Systems and Relationships.     As usual, the electronic medical/health record was front and center.   Not only the usual age-related differences in use and perception….this discussion also focussed on how it is changing the thought processes nurses use.   A very experienced NICU staff nurse mentioned the reality that critical thinking also refers to decisions about what not to do, which is equally as important as the decisions about what to do.   However, the structure of the EMR  requires those decisions to be revisited in order to complete documentation.   That comment just opened the door to more discussion about the control over practice thinking that is mandated by the EMR.   An experienced Delivery Room nurse commented about the problem of trying to put in q2min. vitals during a critical episode (not having learned typing), while another commented on the ease of her system that automatically inputs physiological data from another computer system.   Both realities impact the nurses’ thinking.  And of course, this whole discussion was framed around the issue of relationships….nurse/patient, physician/nurse and nurse/nurse.    The importance of students learning while in school to manage  themselves in these highly stressful situations was made clear, while it is also clear if that skill is not learned in school, it must be learned in the workplace.   Key to healthy relationships is the ability to manage oneself. 

At the end of the evening,  comments reflected the belief that the human contact between patient and nurse is the eternal and important truth about nursing and that there is hope it will always remain at the core of our practice.

Here are a couple of follow-up emails I received. 

Marie,Thank you for allowing me to attend your last Salon with my preceptor, Michael P! I had a wonderful time. You are an excellent cook and an engaging conversationalist!

I am in the process of writing a paper about the CNS impacting organizational culture. While researching, I came across a paper written by Lorraine Hardingham, a nurse clinical ethicist, who defends her position that “as human beings, we are essentially interrelated, and therefore, both personal and professional integrity, rightly understood, is relational in nature.” It seemed to fit with that night’s themes of Systems and Relationships. I attached the article if you are interested.

You mentioned that you’d be willing to send files on how to start a Salon. I hope finish the CNS program in May and pass the certification exams. Then, I would love to start a group here in the Fargo-Moorhead area. Please send your information when it is convenient for you.

Again, thank you for a memorable time of connecting at your home.

With deep regard, Patrick S.

Again, another stimulating evening Marie. I come home all revved up and unable to sleep with thoughts racing through my brain. Thank you so much for these incredible forums! I am able to feed my body and my soul and I thank you. Deb. M

   There was a large group here last night….several returnees and several first-timers.   The mix of newbies and old-timers was energizing, and provided both balance and passion to the discussion.    Mid-career nurses brought workplace dysfunctionality expereriences to the discussion, while students and new grads expressed concern about being accepted as members of a nursing staff after they graduate and about being able to handle the incredible stresses and workloads required of staff nurses in today’s hospitals.   Because we were able to listen to each other intentionally…..we quickly found common ground to express ways to handle various situations within the workplace and to acknowledge the value of the wide age-distribution that exists in nursing today.

One nurse spoke with deep feeling about a terminally ill seven year old whose disfigurement in death was extremely disturbing to this nurse in her second year of practice.   Older nurses were able to help this young nurse see this experience from a perspective that was both comforting to her…..and that allowed her to see the value she brought to this patient by her compassionate presence.  It is this kind of support and perspective that is only available from seasoned nurses who have learned these things from their own experience.

It brought to my mind again the importance of using reflective practices to absorb and learn from the often incredible experiences we nurses have in this work of ours.   In the old days when student nurses lived in dorms….there were usually times and opportunities to talk about the sometimes mind-blowing sights, sounds and smells of nursing….of dealing with life and death and disfigurement.   In todays health care reality nurses often don’t have time to even talk to colleagues at work, and end up suppressing or stuffing un-processed feelings.    These Salons provide that kind of opportunity and really deserve to be replicated.   I would like to help anyone get one started….and have a written description of the way to do it I am happy to share with everyone.

The aftermath to the Summit of Sages has been fascinating. I have been in two major discussions with nurses about social justice with almost explosive results. The first was at the Zeta Chapter of Sigma Theta Tau and the second was a week later at a Salon in my home. At the Zeta Chapter about 50 attendees heard three nurse leaders from here in the Twin Cities speak about the issue of Social Justice from the perspective of their workplace. The first person isCNO of a specialty hospital that provides coordinated care for children with severe developmental disabilities. She spoke of finding there were NO similar services available to their patients as they become adults. The whole segment of adults with developmental disabilities from childhood have no specialty in or out patient service providers. The second speaker is from a local liberal arts college with a major nursing program who spoke about a college-wide initiative to eliminate abusive or violent communications among students and faculty members. And the third CNO of a local community hospital spoke of her previous experience in the Canadian system where no one goes bankrupt or loses their home because of illness and no one dies because they can’t afford health care. She also spoke of the young adults who arrive in their ER due to a sports injury with no insurance because they are no longer on their parents plan and not yet established themselves. After these three speakers, the audience entered into a free-flowing passionate discussion about the fact that as nurses we see the effects of this crazy ‘non-system’ of health care….and yet we seldom speak about what we know. There was a strong consensus about the need for nurses to speak up about what we know and about how we think the system should change.

The second discussion was at a Salon a week later and again, the stories about what we know were overwhelming. A quick summary:

ER Nurse Manager told of 3 patients in 2 weeks who died upon arrival at the ER door, having waited too long because they didn’t have insurance. Upon arrival at the place of help, they simply gave up the struggle. She also told of a man arriving in a friend’s car with a bleeding leg. She looked at it while he was still in the car and realized it was shooting arterial blood. He waited some time for his friend because he couldn’t afford an ambulance.

A Medical ICU nurse told of excessive end-0f-life activities that have astronomical costs for elderly patients with no hope of recovery.

Another nurse told of the multiple-birth cases where 5 and 6 babies are born, most of whom cannot survive but whose care is always extremely costly.

The point that was made over and over again is that as nurses we are at the ‘point of care’ and see the effects of the current health care crises on the lives of our citizens. the discussion ended with a commitment to find ways to speak our ‘truth-to-power’

Last night we had our monthly Salon at my home. About half the group was new and the other half had been here before.   This time only one student nurse came and one fairly new graduate working as a staff nurse and 3 attendees were not nurses, one teaches at health related topics at a local college, one is a retired physician I have known for a long time and the other was a visitor from Iceland who wanted to see how a salon worked.   Most of the rest were middle-aged staff nurses and nurse managers from various hospitals around the Twin Cities.

Although many topics were raised during the initial check-in, we ended up focusing on a wide-ranging discussion related to staffing/resource issues, social justice and inequities in the health care system so often part of the every day life of a nurse.

A manager at a local ER told about three patients who died on the floor of the ER vestibule, collapsing as soon as they arrived, having stayed away from care until the last possible moment because they have no insurance.    She also told of a man who cut his leg and waited for a friend to drive him to the ER as he couldn’t afford an ambulance.    This man had an arterial bleed and had lost enormous amounts of blood before he arrived.   In this ER visits are increasing astronomically while care hours/visit are continuously reduced to increase margins.

A NICU nurse talked about the cost of caring for multiple birth babies (5 or 6) the result of infertility treatments who stay in NICU’s for months.   Often staffing throughout their life is 1:1 or 2 nurses/baby.   The last group six births resulted eventually in one baby actually living.   A nurse manager of a medical ICU talked about the hundreds of thousands of dollars spent during the last few weeks or months of care for catrosphically failing people in their nineties.

The student is now in her public health rotation and wonders why the savings created by keeping people healthy isn’t part of the economic equation.

This may sound like an overall pessimistic evening, but it was far from it.   I can’t really explain what happens at a Salon, but we seem to be able to connect with our positive values and experience strength just from knowing each others experiences and values.

I am definitely sensing from this discussion and others that have been occuring recently that the ‘Voice’ of nursing is in the process of become loud enough to be heard.   I’m not sure just how this will happen, but I sense a real strengthening of our committment to make the world a better place coupled with a awareness that we are strong and can be stronger.

I am encouraging all of us to initiate conversations about social justice in all of our professional meetings.   Specialty organizations looking for great programs for their meetings could do what the Zeta chapter of Sigma Theta Tau did here last week when three nurse leaders presented brief comments about social justice issues in their workplace.   The discussion that ensued was energizing and confidence-building.    This concept of social justice has a rippling effect that continues to strengthen with each new discussion.

The 2007 Summit of Sages was an amazing experience. So many nurses gathered in one place to talk about Social Justice and Nursing. My head and heart are still reeling from everything I heard, saw and thought.  

For me, one of the most moving events was Maya Angelou’s speech and the time she spent with us. 

Walking reverently, majestically, she filled the room with her presence. Carefully seating herself as if fragile, quiet for a moment, she opened her remarks singing: “the rainbow is in the clouds”. This remarkable, beautiful queenly black woman then spoke for an hour, touching on a variety of topics with reverential seriousness, yet delighted the crowd with an infectious smile and keen humor. She occasionally referred to herself as a six foot tall black woman and spoke of her son, of racism, poetry and the meaning of life. 

Throughout her time with to us she frequently returned to the theme of “the rainbow is in the clouds.” She reminded us that rainbows only appear in clouds – not in the bright sunny skies. An act of kindness that seems inconsequential to us may alter the life of the person to whom we were a rainbow in the clouds. 

Dr. Angelou shared the example of her Uncle Willie. Afflicted by almost total paralysis of the left side of body, Uncle Willie earned meager wages as a shop keeper in a small town in Arkansas. However, his condition and small income didn’t deter Willie from being a rainbow in the clouds – touching the lives of thousands and indirectly, millions of people. After the divorce of Dr. Angelou’s parents, Uncle Willie raised Maya and her brother. Stern but fair, Uncle Willie taught them the importance of education, work and ethics.  

On top of raising the two children, Willie befriended a local boy town whose mother was blind and unable to support her son. Uncle Willie paid the boy to do odd jobs and errands around the store, instilling the same values he taught to Maya and her brother. That boy went on to be the Mayor of Little Rock, Arkansas where he would become a Rainbow in the Clouds himself.  

Years later, when Uncle Willie passed away, the Mayor contacted Maya. He wanted to pay the family back for Uncle Willie’s kindness by ensuring his assets and property were protected and allocated appropriately. He met with Maya and gave her the name of a prominent lawyer in Arkansas. This lawyer had a special friendship with the Mayor, as he had been the lawyer’s “rainbow in the clouds,” acting as a father figure, guiding him as a student leader in high school, and helping his mother who had been widowed while only six months pregnant. Later, the Mayor would then help get this lawyer into the Arkansas legislature.  

The lawyer certainly made sure Maya’s assets were protected, but he did much more than that. With his start in the Arkansas legislature, he went on to become the Governor of Arkansas. As a result of Uncle Willie helping a boy in need, another boy in need had gone on to become a lawyer, the Governor of Arkansas, then became the President of the United States: Bill Clinton. 

Interspersed with her stories of Uncle Willie’s shining Rainbow in the Cloud moments, Maya told of being a sixteen year old, unwed, pregnant, six foot tall black girl yearning – but certainly not educated to be – a translator for the United Nations. She contrasted her feelings then with the pride, many years later, at being asked to write a poem for Bill Clinton’s inaugural speech followed by being elated and absolutely awestruck at being asked to write the poem celebrating the fifty year anniversary of the United Nations. 

Between these and other poignant stories, she also used her voice as a musical instrument, singing and calling out, murmuring low and laughing raucously.  

What struck me forcibly was the sub-text of reverence toward life, toward poetry and toward herself as a woman. Her tone, language inflection and facial expressions reflected a deep sense of self-respect for herself and her life. And for poetry. This reverence for women and for poetry embraced the nursing profession. She referred to nursing both as living poetry and as a beautiful example of the Rainbow in the Clouds. 

Tearful and emotional, Maya accepted the honorary doctor of humane letters from the University of Minnesota. You can read more about it, and see the poem she dedicated to us on the School of Nursing’s website.  

As it all settles out I will be writing more, and I know Creative Health Care Management, The University of Minnesota School of Nursing and Creative Nursing Journal will be sharing more details over the next few weeks and months.

I decided to query email list I use to inform people when the Salon is scheduled about why they even come to this event. Everyone is soooooo busy, there are many reasons why not to come. Every once in awhile, I’ll send you their answers to that question. Here are two:

The reason I show-up at the salon is for an up-close and personal dialogue about the state of nursing in a variety of settings. Thank goodness we have so many different attractions to different populations and different settings.
That makes for many career options and we all have a slightly different “take” on the state of healthcare and the state of nursing.

I also find the different organizational stances really interesting.  It makes me feel less alone in both the intimate and public struggle of healthcare.  Sometimes it is a transcendent experience, like after the bridge collapsed and Marty said she felt “we built a bridge here today” as our conversation kept veering back to that sad event.  Other times I get my energy rev-ed up and then feel a bit of a let down as action is up to me and I don’t always see a way.  Most of the time the Salon is a great reflective process to feed my brain and my soul.  I get nourished by the people via their hope, humor, and honesty.  The expectation to just “BE” in the setting of confidentiality and a meal is pure presence that I have not had very often as an adult and never in my professional life. 

In today’s climate of the “Rage Industry,” and where Target customers are called guests, and patients are called consumers, I can come back to my core of nursing in a gentle and intelligent way with good conversation. I find it very good medicine!
DG 

Hi Marie,
I came to the first salon having no expectations nor a full understanding of what I was going to experience. What I found was a diverse group of people that care about nursing and where it is headed. I loved that it was an informal opportunity to explore and express ideas that had been percolating without a ready outlet.

I came back because I think it is a great chance for people to expand their experiences as nurses beyond their chosen patient population and see nursing as a whole. Though we may choose to work with different patient populations we see mainly the same issues arise on every level whether it be short staffing, inadequate leadership (both formal and informal), or lack of participation in unit related activities.

We also share the same love for our patients and their families no matter what their age. We all felt a calling to nursing, and sometimes we need a reminder of what that calling was and why we worked so hard to answer it. I found this when I attended my first salon, and I hope to continue to renew my passion for nursing and search for further solutions through future meetings. Thank you for the opportunity!

Sincerely
HG

A recent dialog among Creative Health Care Management (CHCM) consultants resulted in an internal communication I have decided to share with the blog.  As always, your comments are welcome.  (Also…how do you like the new look?)

This communication about Relationship-Based Care started with a question from Mary Koloroutis via email within our company.   

From Mary to all Consultants: 

An issue that continues to surface in the RBC Leader Practicum and in some interactions I have with nurse managers and unit practice council members is that as much as they would like to implement a primary nursing model of nursing practice, that the acuity, staffing realities (ratios and schedules), and the geography of the unit, create huge barriers to their getting there.   How are client managers addressing this?

Jayne Felgen, president of CHCM, sent this reply: 

From Jayne Felgen to Mary, copied to all consultants: 

It IS the HEART of  RBC…accepting a responsibility relationship for the patient’s care throughout their stay on that unit is the ultimate expression of professional practice.

I’m naming it and claiming it! So, the work of the Unit Practice Council is to review current scheduling and assignment practices (Work Complexity Assessment) looking especially for fragmentation reduction opportunities…to make it more likely that the nurse who agrees to perform the admission activities might also chose to be the primary nurse.

So, like an attending physician retains responsibility despite multiple consultants, or her/his day off, so do nurses create an infrastructure in which they claim responsibility for 1-2 patients among their typical assignment. Once those responsibilities are “owned”, the nurses communicate in more deliberate ways, proactively, more precisely…not unlike a parent leaving explicit instructions for the sister who’s caring for the kids while parents have a get-away. When they return, they resume care. While they’re gone, they’ve anticipated every possible need.

Having said that, 100% compliance with this may be impossible, but, we urge them to shoot for it because it’s the right thing to do. And, using Appreciative Inquiry (AI) principles, learn why it worked when it worked, and then do more of that.

Until we accept this responsibility at this level, we’ll continue to ignore the crazy schedules (1 day on, one off, 8-10-12 hour shifts reporting on/off to each other, robbing Peter-to-pay-Paul floating practices, being married to geography rather than relationship, and other craziness that produces high variability and low professional reward/satisfaction in our systems.

I am abundantly clear that we must step up and claim our practice…not by tasks or shifts, but one relationship at a time…nurses, therapists, social workers, pharmacists, etc. It’s the professional v. technical dialog again.

John Nelson — nurse researcher, president of Healthcare Environments and CHCM adjunct faculty —  frequently shares data with us about the outcomes of our work with our clients. One hospital implementing Relationship-Based Care found that a richer skill mix decreased the dollars per Adjusted Patient Day, decreased ventilator-associated pneumonia and decreased patient falls with injury. John would hasten to add that this is a statistical correlation that does not indicate causality, but only a relationship between variables. I think the more we learn how to interpret and correctly discuss this kind of statistic, the better able we are to explain the importance of adequate staffing.

After the “reengineering” of nursing in the nineties (which had nothing to do with nursing, and everything to do with saving money), we lost sight of simple truths and replaced our authentic experience with “grids” which supposedly save money but which in reality wreak havoc with common sense.

Some truths we need to reclaim are:

• Skill mix should be related to acuity not to a financial goal.
• Changes in patient census should drive changes in total FTEs.
• Continuity of assignment increases productivity (having the same patients two days in a row increase productivity by approximately 25%).
• Use of support staff improves when delegation is based on trust. Working together builds trust, so pairing and partnering leads to the best use of NAs and LPNs.
• Staff should only be ‘pulled’ off their home unit when not to do so will have DIRE consequences. It should never be done just “balance the numbers”.
• Morale of the staff determines quality of care. Morale is a function of how staff members treat each other.

Introducing Relationship-based Care is an excellent way to re-introduce these simple truths and return our profession to “common sense management”.