Want to Achieve the ‘Greatest Good’? Listen to Your Patients

Ethical dilemmas abound in nursing practice. Consider these commonplace scenarios:

* An angry patient threatens to leave the hospital against medical advice. Should you hold him against his will?

* A cancer patient fears chemotherapy. Should you give less detailed information about the effects of anticancer drugs?

* An obese home care patient with pressure ulcers refuses to cooperate in turning. Should you turn her anyway?

Such conflicts between the patient’s wishes and the nurse’s perception of the patient’s best interests occur regularly. That doesn’t make these ethical dilemmas any easier to resolve, but how nurses approach them can significantly affect clinical outcomes. Taking the time to listen to patients—and to integrate relationship skills with principles of ethical practice—can help nurses achieve solutions that are both ethical and appropriate for individual patients.

ky olsen/via Flickr

That’s from the February issue of AJN, in which nurse–ethicist Doug Olsen (who has in the past written for this blog on ethical issues related to mandated H1N1 vaccinations for nurses) offers a thoughtful discussion that may resonate for all nurses who’ve ever faced a situation like those in the above examples. It may seem obvious or cliched to say that listening to patients can help solve apparently intractable problems—but just because listening as a skill is hard to measure doesn’t mean that it’s not sometimes effective where more rigid tactics would fail.

Will Texas Nurse Whistle-blower Case Have Dangerous Ripple Effect?

KERMIT, Tex. — It occurred to Anne Mitchell as she was writing the letter that she might lose her job, which is why she chose not to sign it. But it was beyond her conception that she would be indicted and threatened with 10 years in prison for doing what she knew a nurse must: inform state regulators that a doctor at her rural hospital was practicing bad medicine.

That’s from an article in today’s New York Times about a Texas nurse who’s being prosecuted for blowing the whistle on what she asserts were inappropriate medical practices by a doctor she worked with. We’ve posted on this as the case has developed and also written about it in the journal. Ultimately, the judgment is up to the court. But the concern we’ve expressed and which others have also voiced is that this will have the effect of silencing others who should be speaking out. In the process it may well reinforce old nurse–physician dynamics that profit no one. What do you think?

The Checklist – Taking Finger-Pointing Out of the Equation

By Peggy McDaniel, BSN, RN

Ok, I will admit right off that I am a huge fan of Atul Gawande’s writing. I have read his books Better and Complications, and I think much of his work should be required reading for all health care students. I haven’t read his newest book, The Checklist Manifesto: How to Get Things Right. I plan to soon, but it’s the 3^rd book down in the pile on my bedside stand.

That confession aside, there has been some recent news around the use of checklists that bears some attention. Dr. Gawande helped develop a two-minute checklist that is to be done prior to surgery. 

Dr. Peter Pronovost was involved in the development of a similar checklist related to the insertion of central lines. 

Airlines and airplane manufacturers, such as Boeing, use checklists constantly to ensure consistent, high quality outcomes. 

I did a quick Google search for “checklists and nursing” and found various references to skills and competency checklists. As a nurse, my skills have been observed and validated with checklists over the years. I have also been party to filling out checklists on myself and my peers. Come to think of it, much of our charting has been done by filling out checklists. 

I guess I am a bit surprised that the use of checklists to validate competencies and keep track of specific processes and actions by doctors and multidisciplinary teams has been so long in coming. Much of the current work done in health care around the use of checklists appears to be spearheaded by doctors, but it also supports nurses by promoting open communication between all parties.

Why is it that a simple checklist can make such a difference? When Gawande speaks of the positive outcomes that he has seen from the implementation of his checklist, he admits that he “didn’t think he needed the reminders.” But he also admits that he has not had a week where the checklist did not prevent a problem.

The Pronovost checklist that monitors the insertion of central lines can empower a person, such as a nurse, when they are monitoring the actions of a doctor. The checklist becomes a leveler—it takes finger-pointing out of the equation, and ensures quality by stopping the process if it is not being done properly. The success of such checklists and high quality outcomes can only be ensured when the highest level of the organization is supportive of the person holding the checklist. 

Both Pronovost and Gawande admit that checklists are not a “magic wand,” but they do agree that when used consistently, they have been consistently proven to improve outcomes. Are you using checklists in your place of employment? How long have you been doing so and what do you see as the benefits and the challenges? Has their use made a difference to the patients you serve?

Déjà Vu All Over Again: Internal Uterine Contraction Monitoring Another Case of Practice Without Evidence

by mahalie, via Flickr

By Shawn Kennedy, MA, RN, interim editor-in-chief

Last week, the New England Journal of Medicine (NEJM) reported (abstract available here) on a Dutch multi-center randomized trial comparing internal versus external monitoring of uterine contractions during induced labor on rate of cesarean or instrument delivery. Among secondary outcomes they examined were use of analgesia, oxytocin and antibiotics, adverse neonatal effects, and complications from the intrauterine catheter (hemorrhage, sepsis, among others).

What caught my eye was the first sentence of the paper, which read, “The monitoring of uterine contractions by means of internal tocodynamometry during induction or augmentation of labor is advocated by professional societies in obstetrics and gynecology.” Yet, as this study points out, there has been little data to support the societies’ recommendation for internal monitoring. And, lo and behold, the results of this trial “do not support the routine use of internal tocodynamometry for monitoring  contractions in women with induced or augmented labor.”

This reminds me very much of electronic fetal monitoring.

“I often feel anxious and nervous when I care for a dying patient . . .”

As a nursing student, I often feel anxious and nervous when I care for a dying patient. My classroom lectures have been similar to those given in medical school—death is an enemy to be conquered. We focus on treating the disease process and give very little attention to death and dying.

That’s from a letter to the editor now online in our February issue. The article the letter writer was responding to was “Stopping Eating and Drinking,” which we published back in September. The article is about an end-of-life option that is a choice available to patients who aren’t “actively dying” but who have experienced a radical diminution in their quality of life. It’s also about what a nurse legally and ethically should and should not discuss with a patient.

The notion of a nurse advising a patient on stopping eating and drinking is a potentially controversial one, but the responses we received were surprisingly unalarmed that we would publish such an article. Here’s another letter we got in response. We love to hear from our readers, whether in the old print format or here on the blog.

Normal Blood Pressure — in 1914

That’s an excerpt from an October 1914 article about blood pressure that was published in AJN (our older articles only exist in PDF versions, so click the PDF link in the upper right corner of the article landing page).

Maybe, though, in the absence of the many medications we now have to treat hypertension, these really were “normal” (that is, realistic) blood pressure levels for adults as they aged! It’s funny how, in so many areas, we keep on redefining the meaning of this oft-used phrase: “normal changes related to aging.”

Is the Florence Nightingale Pledge in Need of a Makeover?

FN and her tame owl Athena/IrisDragon, via Flickr

By Christine Moffa, AJN clinical editor

Authors and publishers frequently send nursing– and health care–related books to AJN in hopes we will review them. I love it, so keep on sending them. My latest read is Mystery at Marian Manor: The Adventures of Nora Brady, Student Nurse, a book for young adults. I guess you could call it a Cherry Ames for the new millennium. 

At the beginning of the book is the Florence Nightingale Pledge, something I haven’t read since my graduation in 1995. I have to say it made me cringe. It’s almost as bad as when I visit my parents and see the nursing school graduation photo of me in that silly nursing cap I wore under protest. (If the men didn’t have to wear it, why did I?) If you’ve forgotten the pledge, here goes:

 I solemnly pledge myself before God and presence of this assembly;
To pass my life in purity and to practice my profession faithfully.
I will abstain from whatever is deleterious and mischievous 
   and will not take or knowingly administer any harmful drug.
I will do all in my power to maintain and elevate the standard of my profession
   and will hold in confidence all personal matters committed to my keeping
   and family affairs coming to my knowledge in the practice of my calling.
With loyalty will I endeavor to aid the physician in his work,
   and devote myself to the welfare of those committed to my care.

While it’s hard to disagree with some elements of the pledge, certain parts prompted me to Google the phrase “Florence Nightingale pledge out of date.” I’m pleased to report that I am not alone in wondering about this. Donna Cardillo at NursePower! had a similar reaction this past December:

I recently came across the Florence Nightingale pledge, the one I took 35 years ago when I graduated from a hospital-based diploma nursing program. When reading it on the eve of the year 2010, it occurs to me that it needs to be updated to better reflect where nursing practice is today.

Here’s my updated version: “I solemnly pledge myself before God and in the presence of this assembly, to live my life with integrity and to practice my profession faithfully. With dedication will I endeavor to uphold the ethical, scientific, and legal standards of my profession, and devote myself to the welfare of those committed to my care.”

In the spirit of evidence-based practice—questioning why we do things just because they’ve always been done that way—I wonder if it’s time for an overhaul of  the pledge. How would you revise it?

Emergency—Bleeding Esophageal Varices: What Nurses Need to Know

By Sylvia Foley, AJN senior editor

esophageal varices

This month’s  CE feature opens with a patient with alcoholic cirrhosis who suddenly vomits large amounts of blood. She’s experiencing variceal hemorrhage from esophageal varices, an often deadly complication of alcoholic liver disease, as author Melissa M. Smith explains. Esophageal varices occur in roughly half of all people with alcoholic cirrhosis; about one-third of these will experience variceal hemorrhage.

Smith describes the etiology of esophageal varices, then discusses the risk factors for variceal hemorrhage, noting that risk for initial hemorrhage increases with:

• larger variceal size
• presence of red spots or wales on the varices
• more severe portal hypertension
• more severe cirrhosis, with or without ascites

And the above factors as well as the following increase risk for recurrent hemorrhage:

• severity of initial bleed
• age over 60 years
• bacterial infection
• renal failure
• active alcoholism

Smith discusses emergent treatment and outlines further treatment options, which include endoscopic variceal ligation, endoscopic injection sclerotherapy, balloon tamponade, and transjugular intrahepatic portosystemic shunt (TIPS) placement. The patient case vividly illustrates what can happen when bleeds recur.

Have you cared for patients with variceal hemorrhage? We invite you to share your experiences with us in the comments.

Oh for a Thimbleful of Gratitude!

By Christine Moffa, AJN clinical editor

I had surgery 12/28 and spent four days on med-surg afterwards. I literally spent 3/4 of my time sleeping (bliss! oh rapture unforseen!), but *every single time* anyone came into my room for any reason (meds, IV change, turn off the freaking IV alarm, phlebotomist, housekeeping, whatever), I said “thank you.” I got the feeling I was abnormal. . . . So. How often do your pts say thank you, and does it come as a surprise when they do?

It’s been a few years since I’ve worked directly with patients, but in the past when I had a particularly tough day I would tell people that “nursing is a thankless job.” I’m talking about the kind of day when you barely had time to use the bathroom, never mind eat something, and the only feedback you heard from patients and administration was about what you didn’t get done. So when I saw a post (excerpted above) called “How often do your pts thank you?” at Allnurses.com, it hit a nerve.

by Orin Zebest/via Flickr

The responses to the post were mixed, with some saying it’s common to be thanked by patients and others arguing the opposite. Maybe it’s regional—I’ve only worked on the East Coast, and in my experience complaints seem to get more air time than gratitude. Or maybe it’s just the times we’re living in. Either way, I’m sure most nurses would say they didn’t choose this career in the hope of being thanked all day long. I just think it could make the day a little more enjoyable if you were.

CDC Guidance for Relief Workers and Others Traveling to Haiti

This notice is to advise relief workers and other personnel traveling to Haiti to assist with the humanitarian response following the January 12th earthquake near Port-au-Prince. Conditions in the area remain hazardous, including extensive damage to buildings, roads, and other infrastructure.

The above is the start of a guidance document for relief workers heading to Haiti that is now available at the Centers for Disease Control and Prevention (CDC) Web site. It gives useful information on recommended vaccines; insect-borne and other infectious diseases; key items to bring; safety precautions related to accident risk, exposure to human remains, and animals; and psychological and emotional difficulties.