Nursing Notes

February 23, 2011

Good Grief: Nurses Cope With Patient Deaths

Filed under: Nursing — Shirley @ 12:12 am
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Here’s an article from Nurse.com that talks about the effect a patient’s death can have on you as a nurse.  We all understand that death is a part of living; we are taught what to do for the recently departed; we are taught how to help those in the last moments of living; we gladly stand up and hold the hand of our patient as that last breath is taken.  It’s part of who we are and what we do as nurses.  The problem, though, stems from the humanity we all share.  We are each touched and scarred by a patient’s death.  We cannot help but be.

Please read this article and initiate similar discussions with your peers.  Until we start processing these events, we can not begin to move on.  All of us need to feel free to turn to our peers to discuss this topic because there really is no one else who can understand.

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Rowena Orosco, RN, BSN, had been working at Johns Hopkins Bayview Burn Center in Baltimore for three years when a family with seven children was brought to the hospital after a fire destroyed their home. The one survivor, a 7-year-old girl, was transferred to the burn center with burns over 70% of her body. As the medical team worked desperately to save the girl, Orosco sat with her, crying and holding her hand as she died. This moment haunts the nurse 15 years later.

“I got through that day, but after that I thought about quitting,” Orosco says. Instead she attended a debriefing, exchanged many tearful hugs with colleagues in the halls, talked a lot with a co-worker and kept working. “You kind of put your emotions aside because there are other patients waiting for you.”

Nursing students might learn how to help family members grieve, but seldom learn how to deal with their own feelings of sadness or loss. Research about how nurses cope with patient death is scarce and mostly anecdotal. But what studies there are suggest nurses go through a unique grieving process when patients die, and how they manage this process is important to their well-being.

Only Human

“We feel that when people die, it doesn’t affect our care, which is absolutely ludicrous because we’re human, too,” says Tina Brunelli, RN, CSN, MSN, ANP-C, a nurse practitioner with Novant Health in Kentucky. Brunelli, who has worked in oncology, hospice and critical care, wrote a concept analysis as a graduate student, published in Nursing Forum in 2005, about how nurses cope with patient death.

Stifling personal emotions about patient death has been equated with professionalism for nurses and physicians. “These fields evolved from the military and there are still feelings of, ‘Suck it up and move on,’” says Robert S. McKelvey, MD, a professor of psychiatry at Oregon Health and Science University, Portland, who wrote a book titled, “When a Child Dies: How Pediatric Physicians and Nurses Cope.”

But in interviews with nurses and physicians about the subject, McKelvey found “nurses, on the whole, did a better job [of coping]. They were more open to talking about these things than their physician colleagues.” Those who allow themselves to go through a grieving process seem to be healthier, McKelvey says. Those who hold it in, he says, “pay a price by not being able to deal with their feelings at the time and place.” They may feel reluctant to get close to other patients, have difficulty with personal relationships or have trouble sleeping or eating properly.

How a nurse responds to a first death — and whether he or she is supported by colleagues and supervisors — seems to affect how that nurse reacts to future losses, says Lisa Gerow, RN, MSN, a doctoral candidate at the University of Kansas, Kansas City, and associate professor of nursing at Tulsa (Okla.) Community College. She is the lead author on a report, published in the February 2010 Journal of Nursing Scholarship, which uses interviews with 11 nurses to describe the grieving process after a patient dies.

Nurses may be especially at risk for problems in coping with patient death if they believe they had some responsibility for it or didn’t do enough to save the patient, Gerow says. Many ICU and ED nurses become angry and upset after seeing very sick or elderly patients die in pain after extreme and futile treatments to prolong their lives, says Catherine Miller, RN, MSN, CCRN, clinical education program manager for the ICU and special care units at Howard County General Hospital in Columbia, Md. They might feel they didn’t advocate enough for the patient to experience a “good death,” she says.

Self Care

Some coping strategies, developed over time, nurses say, include: rituals to help the patient and family feel better, such as bringing the family food; attending funerals or posting obituaries; and praying or drawing strength from spiritual beliefs. Some nurses use exercise and relaxation therapies, such as a hot bath, to help ease stress caused by patient death. “The nurses that care for themselves will grieve better,” Miller says, especially if they recognize their…….[read the rest of the article here]

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February 7, 2011

Caring for the Chart or the Patient?

Filed under: Nursing — Shirley @ 12:59 pm
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Here is another wonderful article by Theresa Brown in the NY Times.  I really recommend any article she writes, as I believe she is uniquely able to articulate the thoughts and feelings of the staff nurse so that the non-nursing population can see the problem and can feel the stress that nurses work with.

This article points out the ridiculous need to chart “everything” for all the differing agencies that oversee healthcare today.  Charting now seems to take up the majority of each nurse’s shift.  Patient care seems to have been neglected, or worse, lost to this pile of needless paperwork.

I like her idea of a camera that follows the nurse around so she can concentrate on what she does best–patient care.  Maybe there is a nugget of a solution in this idea.  We need someone, somewhere to address this issue so that we nurses can get back to our patients and away from the charts.

Please do visit this site and read more articles by this nurse.  You will not be wasting your time and you will definitely get a feel for nursing today.

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February 2, 2011, 2:17 pmTheresa Brown

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By THERESA BROWN, R.N.

At a recent medical conference in Miami, I sat spellbound as Dr. Stephen Ferrara, a commander in the Navy, delivered a keynote address describing his work in a mobile hospital in Afghanistan.

Dr. Ferrara is an interventional radiologist, a doctor who uses medical images — CT scans, ultrasounds and the like — to treat abscesses, biopsy hard-to-reach masses, check blood flow and cauterize bleeds. He first went to Afghanistan as a medic, then made a place for himself in the operating room, where he placed micro-stents to restore blood flow to damaged tissue, checked perfusion to save legs that would otherwise be amputated and embolized wounds to stop blast victims from bleeding to death.

It’s undeniably grim work, but done with a driving sense of urgency and very few administrative distractions. It may sound odd and naïve to say this, but watching the presentation, with its slides of horrific wounds, I was surprised to find myself feeling envy. He and his team members were free to attend to the area of greatest need: the patient. They were focused on care to a degree that I am rarely able to experience in my own work in the hospital.

Hospital nurses are required to do paperwork, or “chart,” throughout each shift. We do a full assessment of each patient at the start of a shift, and chart that on electronic flow sheets packed with a dizzying array of drop-down menus. If we have time, we document discussions with doctors, when a patient left the floor and when she came back and how we responded to an abnormal vital sign.

The mantra we all learn in nursing school is, “If it isn’t charted, it isn’t done,” an impossible rule to satisfy. Since what could be charted is infinite, I begin each shift feeling that I have already failed in my documentation.

In addition to charting the events of the day, there are required pieces of documentation that address the concern of one health care agency or another. In 2005, the Joint Commission for the Accreditation of Healthcare Organizations put “falls” on their national patient safety list, so our charting now has to exactingly detail our commitment to fall prevention. The Centers for Medicare and Medicaid Services will not reimburse the cost of treating bedsores that develop during a hospital stay, so a new drop-down menu charts whether a patient is at risk and whether they have pressure ulcers already.

The requirements come fast and furious and often have a flavor-of-the-month feeling. One large insurance company was concerned about a specific type of hospital-acquired infection, so for a while every patient had to be tested for that drug-resistant bacteria. We’re now done testing for that infection but get scolded for not consistently testing for another one.

Certain kinds of lab results get called in to the floor nurse, and we’re supposed to report them to the nurse practitioner or physician who is following the patient. Then we have to chart when the lab called us and when we delivered the message.

All medications must, of course, be charted. Intravenous drugs include a huge drop-down menu for noting the location of each patient’s IV line, a step we need to take every time we give the medication, even though the access location does not change that often. And every time we give a pain medication, we have to scroll through multiple drop-down menus to chart the level and severity of the patient’s pain, where it hurts, how sedated they are and how they describe the feeling of pain.

One accrediting agency is focused on education, so there’s also a separate menu for noting that a nurse provided patient education. Another menu charts more long-term care concerns, an important issue for the board of health.

I have joked that the hospital should install video cameras to record everything that nurses do. Having a permanent record of my actions would mean that all the time I spend charting could be time spent on patients instead.

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.

I had a patient recently whose cancer had recurred and spread. I had bought a button in the hospital gift shop that reads “Cancer Sucks” and was wearing it that day at work. She really liked it, but I knew it wouldn’t be easy for her to get to the gift shop to buy one. So later that evening I visited her room and gave her mine.

“You earned this pin,” I told her. Then I saw her eyes light up with recognition. Someone — her nurse — understood what she was going through.

The care we give our cancer patients is obviously much different from what we do for soldiers who’ve had their legs blown off by an I.E.D., but the threat to life and limb is no less real. I have no drop-down menu for charting “Empathized with patient over fear of metastatic disease and death.” And yet, that’s exactly what the patient needed.

“If it isn’t charted, it isn’t done,” we hear. But as the paperwork demands proliferate, my worry is that if it can’t be charted, it won’t be done.

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