Nursing Notes

December 30, 2011

Goodby, Don Berwick

Here’s an article from the Austin American Statesman written by my fellow nurse, Toni Ingles at Seton English: This is an image of Donald Berwick, w...Healthcare.  I’ve posted her articles before about the Texas whistleblower nurses and the trial.  This article is about the loss of Don Berwick.  Whether you liked him or not, this is a very good article and deserves to be read.  Enjoy the article.

Congress chewed him up and spit him out. Marilyn Tavenner will be a
good replacement for him. She is a nurse, has terrific experience and
is greatly admired by Don Berwick (and by me). Berwick’s immense
respect and confidence in her are demonstrated by his having tapped
her as his top deputy.


For the past 17 months I’ve watched through my fingers as Congress has
slowly eviscerated a gentle, brilliant, apolitical pediatrician and
Harvard professor — Don Berwick. It’s been painful, gut-wrenching and
depressing. Congress will finish him off today, when his resignation
as administrator of the Centers for Medicare & Medicaid Services takes

The words “missed opportunity” understate.

The visionary Berwick, champion for patients, was picked for the job
because his “triple aim” (his words) at health care was the same as
President Barack Obama’s reform goals: improving the patient
experience, improving population health and reducing costs — and
because Berwick had decades of experience successfully achieving those
goals in this country and worldwide.

Through the organization he founded in the early 1990s, the Institute
for Healthcare Improvement, care has been redesigned and hospitals
trained to prevent thousands of injuries and deaths.

How has Berwick achieved these changes? Intractable problems in health
care are identified, and IHI, often in partnership with the Robert
Wood Johnson Foundation, take aim at them.

In the hospital system where I work, we know about Berwick, and we’ve
worked with people from the IHI and the RWJ foundation. In 2003, we
were chosen as one of 13 pilot sites to transform care at the bedside
in medical-surgical units.

Direct-care, front-line nurses were challenged and given full license
and encouragement to develop and test methods to improve care. And
that we did. Many of the innovations Seton nurses designed are
practiced in thousands of hospitals worldwide.

In the eight years since the project began, physicians, patients and
families have become engaged in care; bedsores, patient falls,
infection and birth trauma have been drastically reduced;
communication during shift report has improved; multidisciplinary
rounds are made to enhance discharge planning, teamwork and safety;
patients are checked on hourly; response teams rush to a patient in
crisis before it’s too late; and patient and nurse/doctor satisfaction
and retention have dramatically improved. Hospital readmissions have

Through the transforming care project, in the perinatal area, birth
trauma has effectively been eliminated. Clinicians developed a bundle
of best practices for obstetricians.

This safety initiative has saved the government a bundle of money. In
2003, Seton billed Medicaid $500,000 for birth trauma; in 2009, zero.

Berwick has promoted understanding of this concept as a way to curb
government spending on health care. As part of the Affordable Care
Act, Berwick implemented financial incentives for doctors and
hospitals to coordinate care and improve patient outcomes.

Stunningly, Congress refused to confirm the nomination of this proven,
accomplished and promising leader. Eager to demonstrate contempt for
the Affordable Care Act, Republican demagogues seized on Berwick as an
irresistible target.

They dubbed him Dr. Death Panel. Why? Because he — and the Affordable
Care Act — encourage end-of-life discussions between doctor and
patient/family when medicine can do no more.

In addition, they exploited his remarks as an academic praising
Britain’s health care system for covering all its people and reining
in costs while improving outcomes.

Taking his remarks out of context, Republicans portrayed him as an
advocate of rationed care and socialized medicine. This, despite
Berwick’s insistence all along that the British system cannot be
copied here and that America’s system, having evolved around
insurance, needs its own solution.

If you repeat “Dr. Death Panel” and “rationing care” enough times, you
begin to brand and unfairly define Berwick and the health care reform

Marilyn Tavenner, a nurse and his top deputy, will succeed him. Let’s
hope that she will be able to execute his goals. Congress will be more
comfortable with her, as she is more manager than visionary.

Back to his triple aim. Has his work improved the patient experience?
Yes. Has it improved population health? Yes. Has it reduced costs?

Have we missed an opportunity? Oh, and how.

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December 26, 2011

Please thank your nurse this Christmas

Filed under: Nursing — Shirley @ 11:41 am
Tags: , , , ,

Here’s an article that I found on CNN that I hope you will enjoy.  Christmas is one time of the year when nurses have to sacrifice time with family to care for patients.  It’s nice to see in print that someone, somewhere notices. 


Anthony Youn, M.D., is a plastic surgeon in Metro Detroit. He is the author of “In Stitches,” a humorous memoir about growing up Asian American and becoming a doctor.

You can guarantee that three places will be open on Christmas day: Chinese restaurants, Denny’s and hospitals.

I spent part of last Christmas in the hospital visiting my mother-in-law who was recovering from open heart surgery.  I felt depressed walking into the building that morning.  My mother-in-law treasures the holidays more than anyone else in my family.  Lying in a hospital bed was the absolute last way she wanted to spend Christmas.

But during the time I spent at her bedside, my depression lifted, replaced by an overwhelming sense of gratitude for her doctors, nurses, and medical technicians.  I never felt for one second that her care suffered because her medical team was working on Christmas.  The nurses and support staff were cheerful, accommodating and responsive. One male nurse even wore a Santa’s cap and greeted my mother-in-law with “Merry Christmas” and “Ho-ho-ho” before he took her blood pressure.

Most physicians who work on Christmas – with some exceptions like ER docs – round on patients in the morning so they can get back home in time for Christmas dinner.  Not so for nurses and other hospital employees.  They put in full or extended shifts on Christmas to make sure that all the patients are cared for.  Thankfully, hospitals never close; medical care never takes days off.

Each Christmas, nurses and hospital support staff juggle their work schedules and sacrifice their time, giving up their own Christmases to accommodate the needs of patients.  As I sat by my mother-in-law’s bedside and looked forward to my own Christmas dinner, I thought about the dedicated caregivers who would spend their day changing catheters and cleaning wounds while the rest of us enjoyed being with our families in the warmth of our homes.

Some nurses go way beyond the call of duty.  A few years ago I went to the hospital on Christmas morning to see a patient who had undergone reconstructive surgery.  Her nurse, Sara, smiled as she worked.  Even so, I thought she looked a little tired.  I asked her how she was doing.  She told me she was working her second twelve-hour shift in two days.  She was covering for a nurse who had called in sick.  You would never know it. Sara was professional, caring and attentive to my patient, as well as to the five other patients assigned to her.  I was in awe of Sara.

Operating on almost no sleep, she was spending Christmas working in the hospital, instead of with her small children, and she was going about her job cheerfully without complaint and with consummate professionalism…[read more]

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December 24, 2011


Filed under: Uncategorized — Shirley @ 9:56 pm

May you know peace and great joy this season.  May you receive gifts of good cheer from all you meet.

Merry Christmas!

December 22, 2011

Group says El Paso’s nurse-patient ratios inadequate

Here’s an article from the El Paso Times that discusses the differing viewpoints of what is adequate and safe staffing.  When you have sick patients that are totally at your mercy for safety, how can you skimp on the number of nurses assigned to care for them?  It is a shame that this article will get little to no attention because the topic is being put forward by the nursing union and today everyone hates unions, it seems.

This is a timely and interesting article that I hope you will read to the end and leave your thoughts about.  When nurses strike or threaten to strike it most surely will be because of patient care adequacy or patient safety.  Rarely will you find a nurse who says she/he does not make enough money.


Posted: 12/22/2011 12:00:00 AM MST

El Paso nurses alleged Wednesday that hospitals are jeopardizing patient safety by having inadequate nurse-to-patient ratios.

This is happening with greater frequency, and it has nothing to do with nurse shortages, said members of the National Nurse Organizing Committee (NNOC)-Texas/National Nurses United (NNU).

A group of registered nurses who belong to the organization had a news conference Wednesday across the street from Del Sol Medical Center to bring attention to patient, staffing and pay issues.

The NNOC/NNU said in a statement that nurses have filed 334 formal complaints known as ADOs against Del Sol and Las Palmas Medical Center.

“ADOs (assignments despite objections) are lodged when nurses are given assignments that, in their professional judgment, could affect patient care standards,” the statement said.

El Paso NNOC/NNU members Gloria Givens and Amy Peña said they also are seeking better pay for nurses at Del Sol and Las Palmas, which together employ about 800 registered nurses.

Guidelines for the ideal nurse-patient ratios vary, depending on the level of care required for patients.

The NNOC/NNU members said California is the only state that has codified nurse-patient ratios. Although national guidelines exist, each hospital in the rest of the states sets its own policies and procedures.

“Patient care is our first and absolute priority every day at both Las Palmas and Del Sol Medical Centers,” said Carla Sierra, spokeswoman for the two hospitals.

The allegations made by the National Nurses Organizing Committee (NNOC) about staffing issues at both hospitals are not true. We have been bargaining with the NNOC in good faith, and we will continue to do so in an attempt to reach agreement on a contract.”

At Las Palmas, nurses have complained about inadequate staffing and the treatment of nurses.

“For example, in the neo-natal intensive care unit — where the most critically ill babies are cared for — staffing standards are not consistent with either the hospital’s policy or national guidelines,” the NNOC/NNU statement said. “In the telemetry unit, where adult patients are monitored and cared for — a similar situation exists, where staffing ratios are below standards.”

At Del Sol, NNOC/NNU members said, nurses also have raised concerns with management, at the bargaining table and in individual units, including medicalÐsurgical, cardiac ICU, and telemetry units, about the hospital’s nurses staffing in these units required by the hospital’s own patient classification system.

“The nurses are in negotiations with their respective hospitals, owned by Nashville-based Hospital Corporation of America,” the NNOC/NNU statement said, and added that Hospital Corporation of America continues to rank at the top of the nation’s most profitable hospitals.

Peña said, “This is the time for hospital management to focus on a host of issues related to RN staffing. We have laid out these with detail and towards the goal of a comprehensive policy to ensure patient care standards.”

NNOC/NNU members said they are encouraged by the fact that registered nurses recently concluded a collective-bargaining agreement with an HCA-affiliated hospital in Las Vegas, which incorporates enhanced professional and economic standards.

“The gains we made makes me excited to continue my career in a facility that will really value skilled, experienced nurses,” said Liz Bickle, a registered nurse in the Las Vegas hospital’s progressive care unit.

The HCA Mountainview-Las Vegas contract creates a staffing committee to examine the hospital’s staffing levels. Registered nurses will also receive pay raises of 9 to 19 percent during the contract’s three-year period.

Diana Washington Valdez may be reached at; 546-6140.

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December 18, 2011

Top 10 Nursing Stories of 2011

Filed under: Nursing — Shirley @ 10:51 am
Tags: ,
An oil lamp, the symbol of nursing in many cou...

Image via Wikipedia

Here’s a round-up of the top 10 nursing stories this year that I found at  I only posted the first page here, so be sure to click over to see the remaining 2 pages.  I reread all the stories and each one is important and timely, so be sure to click on them too.


Rebecca Hendren, for HealthLeaders Media, December 13, 2011

2011 has been a tumultuous year as healthcare organizations come to grips with value-based purchasing, rules for ACOs, meaningful use, and financial upheaval. Nursing has dealt with continued cost cutting while also being expected to lead care delivery transformation, improve patient satisfaction, and reduce healthcare-associated infections.

Here’s a rundown of the most popular nursing stories we covered in 2011 in case you missed them or just want to have another look.

1. Five Reasons Nurses Want to Leave Your Hospital
Are your nurses engaged, committed employees? Or are they biding their time until they can go somewhere better? Mandatory overtime and ignored bad behavior are two issues that have nurses eyeing the exits.

2. Suicide After Medical Error Highlights Importance of Support for Clinicians
A tragic story about the death of a child from a medical error turned even sadder in the spring after the nurse who administered the medication took her own life. The incident served as a grim wake-up call for hospitals and how to deal with clinicians after errors.

3. 5 Ways to Retain New Graduate Nurses
New nurses have a difficult time bridging the gap from nursing school to practice and often don’t stay with their first job for the long term. Hospitals can recognize this transition and help new graduate nurses through the transition with these five strategies that ensure they are engaged, long-term employees.

4. Does Mandating Nurse-Patient Ratios Improve Care?
The debate intensified as more than a dozen states considered laws to establish hospital nurse-to-patient ratios. This article examined whether patients get better care, experience fewer adverse events, and have shorter lengths of stay and lower mortality with ratios…[read more]






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December 15, 2011

New Facebook Fan Page Created

Filed under: Uncategorized — Shirley @ 6:49 am
Tags: , , ,
Česky: Logo Facebooku English: Facebook logo E...

Image via Wikipedia

I have just learned how to make a fan page on Facebook.  It was really quite easy and you can do quite a bit more with a page than with your personal profile.  I hope you will check it out and like it if you do.  Right now, there’s not much on it, but I intend to change that soon.  I’m working on autoposting from this blog and from another to that page, but I am still learning how to do that.  I hope you will try this for yourself.  Making Fan Pages is really fun!

Here’s the link:!/pages/Nursing-Notes/290893507619413

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December 10, 2011

A growing number of registered nurses in California, U.S.

Filed under: Nursing — Shirley @ 8:17 pm
Tags: , , , ,

Here’s an article from the Los Angeles Times that I found very interesting.  At first I read this thinking, “Great, a good article about nursing for a change.”  Then I reread the article and had a change of heart.  It seems that California, a state with a legally mandated nurse-to-patient ratio, is seeing more growth in the nursing field than any other state.  Imagine that–hmmm, I wonder why that might be?

Then the Rand Corporation goes public to announce THE END OF THE NURSING SHORTAGE is at hand!  But not until 2030.  Isn’t next year 2012?  Sounds like a lengthy shortage to me.

Then, this article talks about a Cardiac nurse, a Nurse Practitioner, and a Research nurse who wants to be a Nurse Practitioner.  Where are the lowly bedside nurses?  Why are we never consulted or included in these events?

I think I must be extremely biased, but you read the article and make your own conclusions.  Let me know what you think of this article, won’t you?  Maybe I am way off track, but I don’t think so.

If the trend continues, say researchers at the Rand Corp., there may be enough nurses by 2030 to meet the projected needs of aging baby boomers and the expansion of the healthcare system.

By Anna Gorman, Los Angeles TimesDecember 6, 2011

Lauren Mills’ counselor in college pushed her to consider nursing. She heeded the advice, graduated from Cal State Long Beach in 2007 and now works with cardiac patients at an Orange County hospital. It’s proved a challenging and gratifying choice, said Mills, now 27.

“You are using your brain and in a way you are using your heart too,” she said. “You feel good when you go home. You feel you made a difference.”

Increasing numbers of women like Mills are helping swell the ranks of registered nurses, easing chronic shortages in both California and the nation, according to a study released Monday by the Rand Corp.

Nationwide, the number of registered nurses ages 23 to 26 grew from 102,000 in 2002 to 165,000 in 2009, according to the study. The current cohort of young nurses is expected to be the largest ever, the study said.

If the trend continues, there may be enough nurses by 2030 to meet the projected needs of aging baby boomers and the expansion of the healthcare system, researchers said.

“Compared to where nursing supply was just a few years ago, the change is incredible,” said David Auerbach, lead author of the study. “If it keeps going, it turns everything on its head and it’s a major revolution.”

California has seen an even more dramatic rise in the number of new nurses, said Joanne Spetz, a professor at the Institute for Health Policy Studies at UC San Francisco. “We are seeing a lot of young people entering the field, which is fabulous. These are the people we need to be moving into the nursing workforce.”

More than 11,500 people graduated from California nursing schools in 2010, up from 5,300 in 2002, according to a report Spetz did for the California Board of Registered Nursing. Much of that is due to a concerted effort by hospitals, foundations and policymakers to expand nursing school slots, she said.

Researchers previously predicted that the U.S. could be short as many as 400,000 registered nurses by 2020. In California, experts believed that the state could see a shortage of about 89,000 by 2030…[read more]

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December 2, 2011

More on Grief and Loss

Filed under: Uncategorized — Shirley @ 9:08 pm

As I am personally experiencing some of both, I found this article to be helpful.  I hope to get another guest posting but the author after the holiday season is over, but for now I will post this article she sent me.  I recommend her book and hope you will visit her website for more information about her.

I would like to invite other nurses to guest post here on this blog.  I try to make this blog a place to come and find viable and current information that reflects on the nursing profession as a whole, but most importantly, on the nurse at the bedside.  Any information that I can produce to empower that nurse, to educate that nurse, to give that nurse a voice is what I aim for here on this blog.  If your writings fall into that catagory, I would love to have you guest post.



                                                                              By A. Barbara Coyne, Ph.D, MSN


Loss: Ever-Present in Living


“The hour that gives us life begins to take it away”…Seneca, first century philosopher

In the unfolding spiral of living, loss is inevitable and universal. If we heed the wisdom of Seneca, we know that we experience loss from the moment of birth until our own death. And throughout the subsequent twenty centuries, we have known that grief is the natural companion of all loss. Although much of what we know about grief is rooted in post-death grief, we also know that we experience other losses: we are connected to people, animals and things and when any of those connections break, we grieve and mourn. Some of these “other losses” include but are not limited to: loss of a job or home, friends who move away or choose to no longer be our friends, chronic but not life-threatening health conditions, divorce, separation and, of course, death (of people or beloved animals).


Every loss leaves an indelible print on the very core of one’s being and each becomes an integral aspect of the unfolding biography that makes you uniquely you. It is this uniqueness of each grief story that renders meaningless the well-intentioned cliché: “I know just how you feel because I’ve been there”. No one experiences your grief in your way. While there are identifiable commonalities in how grief shows itself, each individual’s experience of grief is unique in light of the meaning, context, and current circumstances in which the loss is embedded. Every loss, then, becomes a part of the historical context in which a loss in the present is experienced and expressed. It is in this sense that grief is over…but it’s never over: it changes over time as we learn the lessons that grief, our internal healer, teaches.


Grief: The Internal Healer


 Look well into thyself, there is a source of strength which will always spring up if thou wilt always look there.”…Marcus Aurelius, Stoic Philosopher and Emperor of Rome (161-180 A.D.)   

     Grief, the natural response to all loss, is a fundamental aspect of our humanness. It represents a vital energy within the healing life force, the creative power in all of us that propels our on-going shifting, changing growth. We can think about this vital energy as the “wisdom of the body”—a very old concept having to do with the body’s power to heal itself. This idea has changed over time, stretching from the ancient temples of Asclepius, god of healing, to the modern versions of “stress theory” in the medical model. But it is in the ancient sense of a healing life force of the whole person—not the modern construction of “body-mind-spirit” or “bio-psycho-social parts”—that grief can be recognized as our internal healer.


In this perspective of grief as internal healer, we recognize that grief is not a sickness from which we “recover” in a prescribed timeframe through the well-known five stages: it is the very essence of the human condition in whose wake we learn to live. The learning surfaces as we willingly, albeit reluctantly, engage the difficult process of the work-of-grief…not to be confused with the psychoanalytic concept of “working through issues”.  It is a process that sends us deep inside to wander through the depths of our pain, honor the truth of what we find as we seek the “strength which will always spring up if thou wilt always look there”.


The Process of the Work-of-Grief: Discovering and Creating New Meanings

        The Essence and the Elements of the Process

v    The Essence:

           “Adopt the pace of nature—her secret is patience”….Ralph Waldo Emerson


The very essence of the work-of-grief has to do with using energy to heal the pain of loss as we struggle to discover and create different meanings in a world that seems suddenly chaotic and meaningless. All life processes require energy: from the fundamental basics of cellular function to the increasingly complex human engagement with living, we use vital energy and constantly revitalize it in a variety of ways. Since all losses are embedded within the on-going process of living, when we experience a loss, grief—that internal healer—alerts us that we are now using even more of that vital energy. It explains why one of the “identifiable commonalities” in the experience of grief is an unremitting and overwhelming fatigue. It is this further depletion of vital energy that can contribute to making us sick. Respect this “wisdom of the body”: it is telling us to gentle down, slow our pace, attend to the myriad messages coming from within, nurture our patience and carefully nourish our “self” as we embrace the difficult process of the work-of-grief. It is a time to “adopt the pace of nature”, whose secret is “patience”—to help us tolerate the pain of loss as we inexorably move toward relinquishing our grief through actively embracing the elements of the work-of-grief.


v    The Elements: (three simultaneously unfolding elements)

               “The only way out of the desert is through it”……An African aphorism      


  • DISCONNECTING-CONNECTING which has to do with disconnecting from the familiar rhythm lived with the person/thing lost and at the same time, connecting with the unfamiliar pattern your life is now taking. This creates a profound struggle as you try to “understand” and “make sense” of your loss—as you


  • NARROW THE KNOWING-BELIEVING GAP . “Understanding” has to do with knowing and believing, two different ways of interpreting our world: knowing has to do with “facts” before us; believing has to do with coming to know these facts from our inner experience of them. There is often a wide gap between these two ways: it’s why a common expression following a loss is some variation of “I can’t believe it”—even though you know it: you saw him in the casket, touched him and knew he didn’t feel alive; you hold the divorce  papers in your hands; your friend has moved across the country so you don’t see her every day, your beloved cat does not greet you at the door—so yes, you know it, but you do not believe it: yet! And no, this is not the psychiatric mechanism of the stage of “denial”. It is the “wisdom of the body” offering you a slowing of the process as you come eventually to narrow the gap between what you know and what you believe. You come to this understanding in myriad ways as you live the reality of your changing pattern of living.  FOR EXAMPLE, EACH TIME YOU:


  • reach for the telephone to call your mother for your “daily 3:00 call…..
  • wander through your “empty house’ in the after shock of your spouse’s “moving out”….
  • see the dog’s empty dishes…
  • wonder why and how this could have happened….
  • question how or what you could or should have done better/different/sooner/not at all……….you are narrowing the gap!

Many similarities cross the spectrum of loss—whether related to death, divorce or separation; whether from person, animal or thing. But there is at least one significant difference: for those grieving a loss through death, the reality becomes more concrete in light of the absolute finality of death; for separations or divorce, the person is still “out there” and while communication may be changed or non existent, thoughts of “what if” persist over time. It is important to let all this confusion and disorientation tumble through you as you grieve and mourn your loss…..inexorably you


  • RESOLVE THE WORK-OF-GRIEF which has to do with becoming more familiar with your changed living pattern. Grief, your internal healer, has guided you through this very painful process, to a higher order of wholeness as you integrated new awareness, explored  some difficult truths about connections, relationships and ways you participated in the rhythm of their unfolding. You tolerated the discomfort of engaging the truth presented in your questions and doubts.  In search of peace and perhaps serenity, some choose not to engage their truths because the risk of “seeing” may be greater than the risk of “not seeing” and yet, profound growth surfaces in our willingness to honor our truths, no matter how painful or incongruous. The theologian, Reinhold Niebuhr said it this way: “The final wisdom of life requires not the annulment of incongruity but the achievement of serenity within and above it.” You have lived the incongruity and found your way “out of the desert of your grief”.


     And finally…grief always offers us the opportunity to grow in light of the many losses throughout living. We embrace this growth when we acknowledge the transitory nature of life, hold firm our beliefs and values, honor the truth of our participation in the world and focus on the gifts we have to give. With Hemingway, who tells us (A Farewell to Arms) that “the world breaks everyone, and afterward many are strong at the broken places”, we embrace the strength at our broken places—and we create different ways to be happy.


This perspective can be further explored in my recently published book: You Don’t Have to Like It, But You Do Have to Live It (Visit me at )