A Rude Awakening: The Nursing Struggle

Rating: 5 out of 5.

What is nursing?  Nursing is a state of mind, a passion, a life some of us chose and for some, it chose us. Our battle started with prerequisites and the struggle getting into nursing school.  Then when we found out when starting our nursing school journey that we were already in over our heads on the first day!  Nursing theory for roughly 20 hours while clinical for another 20 hours on top of homework, working around school, studying and juggling family life.  Some students are single parents with no help or social support, I certainly know this to be true!  Everyday going nonstop and trying to hang on, then a test would come, some of our fellow classmates would be crying and others sitting in solitude trying to figure out where they went wrong.  Others, the slim number of other classmates would be smiling and quietly reading until class resumes.  We learn the importance of protecting ourselves to prevent the spread of infection, to adhere by policies from governing bodies, all while juggling 10 different tasks at any given moment to save lives on a daily basis.  Nothing prepares you for the day you set on the floor as a new nurse.  Winging it on a prayer, the nursing warrior makes it out alive with massive student loan debt from working part-time during school, if they are lucky, missing their kids school events, birthdays, or even knowing what it is like to take a break during the 2-3 years of attending the basic Registered Nurse program.  Don’t let me leave out the Licensed Practical Nurses that struggle battling to taking the same type of curriculum over but for a second time to become a Registered Nurse.  This is even more badass!!  Between Nursing Theory, Clinical Rotations and Homework, the average nursing student is putting in approximately 60 hours of blood, sweat and tears to take care of patients and their families.  They say you never understand nursing until you go through what most of us recall as the best/worst experiences of our lives.  Would we replace it?  Never!  We are just working to make it even better!!

How is our profession the best?  We care. While most professions count the minutes to clocking out, we make sure your family is tucked in, questions answered, and the relentless charting completed to make sure everything we have done for you is documented.  Don’t get me wrong, some days we want to 9-yard dash out the door but in reality, who are we fooling, we have wayyy too much to do and a moral character a Rhino couldn’t breakdown.  In times of despair, we choose to listen, sit down and give you company, despite the 5 different ways we are being pulled.  At times, more times than not, we don’t even get a bathroom break, eat lunch or get away to sit down because you are our priority.  We do without so you have that friendly face when you are tired of not being heard, the one that you see being punched or screamed at the patient across the hall. We manage to quickly bounce back, hiding our anguish and feelings the best that we can so you can feel comfortable. We know how to be flexible, adapt and be resilient, even we shouldn’t.  Our humor can be so gross to a regular person, but to the rest of us, we will be laughing so hard that we may snort when we laugh. 

My nursing family knows how to have gatherings at work, to make a co-worker feel special, even when they are trying to recover from the last patient they lost.  When you are grocery shopping or have an emergency, your first responder is more times than not, a nursing professional, whether it is our lovely Nursing Assistants, an LPN, RN or NP, we are there for you.  We give insight, not advice on your boo-boos and if you should go to the ED or to possibly put a bandaid on it.  We are loyal to what we do and advocate for you behind closed doors, this is even when you think nobody is on your side.  When the doctor makes an error, bless their soul, we are there to make sure your care is correct and do our best to help you through the health challenges.  Through it all, we there for you when your family is at home, to hold your hand when taking your last breath, caring for you at your darkest of hours all while putting on a smiling face to greet a new admission.  It all sounds like doom and gloom, it can be, especially now.  It isn’t very good for my nursing family. Nurses are being furloughed, fired, contracting COVID-19, dying, and trying to help the public understand that this virus is real, and not fake.  This is the new world that our nursing students are graduating into. 

Now more than ever, we need your help!  We have the biggest challenge ever, COVID is ramping back up and we need the public to know that your nursing neighbor, friend, sister, brother, uncle, aunt, cousin, mom or dad need your help.  How can you do this?  Please wear a mask, wash your hands, practice social distancing, and call your local representatives to back our profession.  Our Frontline Nursing Warriors need proper respirators and PPE.  We also hope the public will be patient with us when they are are sick, as hard as it is, we are doing the best that we can with what we have available to us.  Nurses and nursing assistants are on the Frontline of the pandemic, they are contracting COVID and being assaulted both verbally and physically by patients on a daily basis when working with all patients.  We did not sign up for this, it isn’t a part of our job.  If you see a nurse or a nurse’s aide being hurt, please report it for them.  They may not be strong enough to say something.  

Please your Nurse or Nursing Assistant know about our Facebook online support group Nurses Against Violence Unite, Inc.® http://Facebook.com/groups/NAVUnite it is Free to Join and participation is welcome!

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Dr. Sandra Risoldi

Nursing Assignment Danger.

The medical-surgical nurse gets the report on a 49 y.o. man, that fell into a thorn-bush and a foreign body is embedded into his arm. Nurse Allen, who is a seasoned nurse has 4 patients and is receiving a report on Mr. Smith. Allen’s current assignment is an ORIF (hip surgery) completed 2 days prior, MI rule-out, a pain management client that has been requesting PRN pain meds on a scheduled basis since last shift, and a patient that was unresponsive under a bridge yesterday that tested positive for opioids, THC, and alcohol, with a BAL 378, that in the ED was rebounding with IV fluids. Mr. Smith was admitted yesterday and being held in the overflow ED area until some unit beds were discharged. Allen is having a very eventful day as usual and extremely busy, so are the other nurses.

The patient finally comes to the floor, IV is halfway out of the patient’s arm, the site was now edematous and told that it must have just happened enroute. Nurse Allen asks for assistance for the vitals and he would be right in to say hi to the patient and start their head to toe assessment. Allen stops the fluid, assesses the area and starts another IV site then starts working on the skin assessment. Nurse Allen immediately sees multiple dots/lines in a row that are healed over but the area on his forearm is red, angry, swollen and painful to touch. Mr. Smith was diagnosed with cellulitis and is ordered to start IV antibiotics with an OR consult. Nurse Allen starts the antibiotic therapy, antipyretics, and the patient had a visitor. This was a particularly normal person, a female that holds some resemblance to Mr. Smith and introduced her as his sister visiting out of concern for his well-being. Nurse Allen attempts to take a break, notifies his colleagues and is so excited that he can get to the coffee shop for a little pick-me-up. The charge nurse Maggie walks in to adjust Mr. Smith’s IV pump, it is beeping and annoying the patient in the same room. When Maggie walked in, she saw Mr. Smith actively using a needle to inject a brown liquid into his IV line, this is why the pump was beeping. A code blue was activated as the patient was slumped over and leaning against the bathroom wall, a needle hanging out of his IV tubing.

This patient was sent to the ICU, nurse Allen was written up for not adequately performing a skin assessment, as the needle casing imprint was on the patient’s leg, where the TED hose was pushed down. A blood test was performed, the patient tested positive for opioids and meth that was injected into his arm. Should Allen be liable if the needle was not there during the skin assessment and was possibly brought in from the visitor? Some say absolutely and others may not see it that way. Security is minimal in all healthcare facilities, so much that nurses and CNA’s are unable to keep up with their own assignments and tasks than to be in the room observing contact between a patient and their loved one. Syringes, along with many other objects are being “pocketed” in rectums or flesh folds, not to mention the female genitalia or even brought in by friends and family. This article is not to condemn those who are addicted but to bring awareness about addiction and how it is straining healthcare workers, who are not adequately trained with nursing education or from their facility. Furthermore, a set up for failure. It is not fair or right that nurses should feel that standing up for what is going wrong in healthcare that it is pointless to report. Many lives that we work with depend on healthy nursing staff, we cannot remain healthy if not protected from harm or have resources to become a stronger and a happier workforce.

If you or someone you know that needs a voice, please join us on Facebook at: Nurses Against Violence Unite (click the business name) and join our community today, feel the difference and supported.

Ready or Not!

We are in a nursing crisis.  Working in nursing pretty much all of my life, I have seen a lot of issues from patients spitting, punching, biting, kicking and slamming nurses against walls.  Is this behavior acceptable?  Absolutely not!  It has been my mission to advocate for others and help them to advocate for themselves, so helping nurses is one of my highest passions.

Nearing the end of my DNP (Doctor of Nursing Practice) project and program, I am honored to have had the privilege of working with some of the best healthcare professionals that have helped me navigate through the doctoral process.  They have helped me grow my focus instead of patient on nurse abuse but the overall picture.  It took me a very long time to get others around me to see the problem and proud that they would look at me like I was insane!  Needless to say, it is important to educate everyone about the issues that we face and give support to all nurses and healthcare workers.

 

Circle of Violence

Lateral and patient/family on nurse abuse has gotten so out of control that in the news we are reading more and more nurses are committing suicide.  We need to really help ourselves as nurses, through education and helping one another or the violence is only going to get worse.  Some may agree with what I am about to say, others may really get offended, but as nurses, we need to hold ourselves accountable and fix what we can with this mess we are in.  Legislation is what we also need for increased security and mandate hospitals to provide protections, but also education to keep us safe.  My goal is to help nurses through education and to hopefully prevent another injury.

So let’s be objective, shall we?

Here is a scenario:

Nurses suffer an enormous amount of abuse —>  Nurse has her 5th admission for the day—> Nurse cannot eat or go to the bathroom as they are slammed! —> Nurse files a report about the verbal or physical abuse —> Nurse Manager starts writing the reporter up for things they did wrong —> Reporting Nurse tries to recoup and stops reporting —> Nurse still has not had a break since she started the shift, even yesterday for that matter! —> Nurse sneaks to the bathroom —> Nurse is being paged, bed 8 is screaming —> Patient is punching the nurses’ aid —> Nurse tries to stop the battery, blocks the CNA and gets hit.

…How would you feel?  Pleasant?  Hardly!  Definitely defeated, upset, feeling like you could do more, what did you do, and in pain but afraid to report it because you know that you are under a magnifying glass.  Face it, we are human too and have a tough job without a moment or a day to recover, we are forced to get back up and keep going.  If the nurse is needing help and asks for help, will she get it?  Probably not because all the other nurses are busting tail just as much as the nurse that needs help!

Will the nurse manager step in?  Maybe or maybe not, depends on how their boss views teamwork and patient care.  If the nurse manager calls into her meeting, will the DON or administration be forgiving?  Wait…she just wrote the nurse up, no way is that nurse going to her!  The patient is #1 but also, what about the nurse?  Staffing is bad, patients are mean, the staff is grouchy, bed 8 just clocked her in the head…and this has the other 6 patients to care for.  Smile and keep going is the current culture of nursing and we are losing nurses just as fast as gaining them to an already struggling profession.

As a side note, I decided to look into how much education there is on acute mental illness, addiction in nursing school.  Barely any.  The Florida professional and practical nurse frameworks have minimal requirements for mental illness and substance abuse.  Is there a de-escalation program offered to nurses on med/surg?  Probably not!  Injuries are not being reported due to retaliation and accepted as “a part of the job” and “nobody will do anything anyway”.  So being that nurses are in fact human beings, the nurse may indirectly start behaving like an abuser.  Yes…I know I am about to get blacklisted from the unapproving reader but really think about it.   How much abuse can 1 person take?

Is this nurse going to be happy or mean?  I would have to say appearing to be quite kind and happy but the underlying personal family history and built up pressures or abuse, maybe not.  This nurse may be having increased anxiety progressing toward burn-out and post-traumatic stress disorder (PTSD).  Some may call it compassion fatigue, to me, that sounds like another fancy name to cover up a huge problem in nursing.  Police and first responders get more recovery time than a nurse!  The nurse calls off, the floor is short, no fill-in for their spot….so nurses have increased their patient load by 1 patient.  Will they be happy?  Probably not.  Will there be increase patient errors?  Unfortunately yes, it puts the patient and nurse at risk.

Education is power and the elimination of violence in the workplace.

Workplace Retaliation

The theme of my research is patient violence against nurses…but there are more sources.  Nurses have messaged and thanked me for taking the stand against violence in the workplace.  When I took on this sensitive topic, it was apparent that this would be a very unpopular topic among employers.  I too have been retaliated against throughout my career, but that has not stopped me.  I feel that it is important to bring our profession up to speed with the rapidly changing patient population through education and tactics to decrease our nurses from being injured.

Retaliation is when someone returns a perceived attack.  The nurse reporting is not attacking the organization but truly trying to bring to light an issue that is occurring on their unit.  When looking at the nursing indicators laid out by the American Nurses Association, it was not surprising to see that psychiatric physical assault and nursing turnover were both on the list.  I personally have seen and talked with nurses that have been injured, that have stated they have reported a physical attack and have been told that they perpetrated and caused the person to attack them.  All the while the nurse stands in their own blood, suspended until an investigation is completed…with no pay.  So about underreporting…this is one of the reasons.

Understanding the bottom line and the costs involved in advertising, interviewing, hiring, and training new nurses and nursing staff, is it truly necessary to look for new help when you already have great nurses?  Not at all.  Playing the advocate role for the nurses that leave their positions, a majority are leaving because they are not being heard, tired of being hurt by patients, while being told that they could have done a better job.  When a patient hurts them, the nurse composes themselves trying to brush it off, while smiling and caring for the other 4-6 patients that they are assigned…without a bathroom break…or lunch…or a moment to sit down to rest.  If the nurses and nursing staff report a problem, please listen, we are on the front line of patient care.

I love being a nurse, we are a tough bunch that love our patients.

Shouldn’t we be loved too?

 

WPV: Reporting Barriers

The one thing that I have found while educating the staff over the years, is a mix of psychology where most nurses are taught between 2-4 weeks of psych in their rotation and want more understanding about how to treat this population.  The next area is negative reinforcement by rewarding the bad behavior, such as ordering more pain medication, giving PRN’s on a timed basis just so they “will have a good shift and not get beat up”.  When a nurse understands the importance of why reporting is necessary, I have found they are more receptive.  The holes of the computerized system not relaying the “misc” data, which is where WPV is reported, does not label or track the data.  The computerized reporting system does not have WPV as an option and if it is charted as miscellaneous, it is not capturable for statistical reasoning.  The average time for reporting in the computerized system is 10-15 minutes juggled between the other 4-6 patients that also may not be staffed according to acuity.  The nurse simply does not have time.

Another barrier, which is pretty huge, is the fact that when a nurse is hurt and reports the incident, there is no provided light duty so the nurse is forced to out on worker’s compensation and to use their banked time (PTO) to make up the difference.  Let me stress…the nurse is not only injured, but they are victimized again by being forced off the floor due to not having provided light duty and a third victimization by losing their hard earned and rewarded PTO time.  In some facilities, sick time is PTO.  As a result, the injured nurse forces themselves to manage, report it to the next nurse, and keep on moving with a smile as patient satisfaction is #1.  The end result, the nurse developing burn-out and possibly Post-Traumatic Stress Disorder.

Environmental Exposures of Mental Illness

Mental health can be affected by various environmental agents.  Several contributors that enhance and bring about mild to acute mental illness include nutritional deficiencies, injuries, alcoholism, illicit drug use, or victimization (National Institute of Mental Health [NIMH], 2017).  Situational stress, such as natural disasters or seasonal affective disorder, can also be a causative agent of an individual’s mental well-being (Heekin & Polivka, 2015).  Mental health can also be a genetic factor.  In 2016, adults suffering from mental illness reached approximately “44.7 million, where women were the largest population affected at 21.1 percent versus the males at 14.5 percent” of the total amount presented (National Institute of Mental Health, 2017, figure 1).  Due to the nature of women having a hormone imbalance, such as serotonin, where levels can be low and be a contributor to developing depression and anxiety (Young, 2018).  A combination of “lower socioeconomic status or stressors” that are related to “job loss, financial hardships, and changing schools” are a few additions to increasing mental illness among both females and males (Heekin & Polivka, 2015, p. 5).

Environmental health risk

As we all know and have heard that when you lead a stressful life, you can become ill.  There are many outcomes from the environmental exposure to stressors.  There is a decrease in life expectancy by “10-25 years”, which could be a result from the development of chronic diseases, such as “heart disease, infectious disease, hypertension, diabetes, and suicide” (World Health Organization [WHO], n.d., para. 1).  Nearly “one in five adults in the United States lives with a mental illness”, which equates to “44.7 million individuals in 2016”, with individuals between “18-25 years with two or more races” (NIMH, 2017, para. 4).  With a large number of those with mental illness comes with a cost of “$89 million in 2013, and with serious mental illness, $193 million reported in 2008” (Kamal, 2017, figure 27).

Health disparities

While working with acute mental health patients for years in various healthcare environments, the background of those I worked with were from a lower socioeconomic situation, including those that are homeless.  However, mental illness can affect anyone.  For the purposes of this discussion, when you have someone that is suffering from mental illness, they often do not keep up with their appointments or check-ups with the psychiatrist or with the primary.  Not to seem controversial in our discussion, but from my experience, patients that are hard to talk with, such as those with schizophrenia, borderline personality, or bipolar, nurses really have a hard time separating the subjective from the objective data.  When a patient says they are fine and ramble off into a tangent, the nurse will get nervous and either end the physical assessment stating that were non-compliant or they take for granted that since the appearance looks normal that they are of sound mind.  To fix this issue, effective communication would be the key to help the nurse to complete their thorough assessment and not the issues the patient may be having.  More times than not, I have found abscesses and septic patients from my time on the floor which infection can also contribute to behavior issues.

References

Heekin, K., & Polivka, L. (2015, November). Environmental and economic factors associated with mental illness. The Claude Pepper Center, 1-16. Retrieved from https://coss.fsu.edu/subdomains/claudepeppercenter.fsu.edu_wp/wp-content/uploads/2016/02/Environmental-and-Economic-Factors-Associated-with-Mental-Illness-Manuscript.pdf

Kamal, R. (2017). What are the current costs and outcomes related to mental health and substance abuse disorders [Report]. Retrieved from https://www.healthsystemtracker.org/chart-collection/current-costs-outcomes-related-mental-health-substance-abuse-disorders/#item-eighteen-percent-adults-united-states-mental-behavioral-emotional-disorder

National Institute of Mental Health. (2017). Mental illness. Retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

Schmidt, C. W. (2007, August). Environmental connections: A deeper look into mental illness. Environmental Health Perspectives, 115, A404-A410. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1940091/

World Health Organization. (n.d.). Premature death among people with severe mental disorders [Report]. Retrieved from http://www.who.int/mental_health/management/info_sheet.pdf

Young, J. L. (2015). Women and mental illness. Retrieved from https://www.psychologytoday.com/us/blog/when-your-adult-child-breaks-your-heart/201504/women-and-mental-illness

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Reporting: Patient on Nurse Violence

          There is an influx of verbal and physical abuse that is affecting nurses throughout that United States and the world.  According to the American Nurses Association in the latest survey and response to the Joint Commission sentinel event, is that “62 percent of nurses had experienced verbal or physical abuse” (American Nurses Association [ANA], 2018, para. 4).  Working on the floor myself for 26 years, until last year taking a teaching position, verbal and physical abuse is a common occurrence no matter what unit that you worked on.  Experiencing first hand the morale of the staff when it came to the effectiveness of reporting incidents to the unit managers or administration, and nothing changes.  The rationale given by nurses is that they believe that their patients are not in their right mind when they lash out at the nurse and leaves them unsure of what constitutes as a violent act (The Joint Commission, 2018).  The nurses that do report the incident usually give a verbal report of the issue to the supervisor, and since it is not in writing, the incident may not be available to pass along for policy changes (Arnetz et al., 2015).

Strategies for stakeholder participation

            Awareness of the problem and formulation of a plan is the first step in the process of creating a policy (Laureate Education, Inc. (Executive Producer), 2011).  One of the strategies for stakeholder participation is through implementing an education plan for nursing professionals and practitioners focusing on the barrier to reporting incidents.  When analyzing the structure of an organizational policy that is in place, the facility should have reported data in their system, if not then this would be the best place to start.  The goal should be finding out why there is no data that reflects patient on nurse injuries.  When nurses state that they obtained lasting injuries, then ask them if they reported it, many times they will tell you no due to “nothing being done to fix the problem.”  One reason for underreporting can include a “lack of reporting policy, lack of faith in the reporting system, and the fear of retaliation” from the organization (Occupational Safety and Health Administration [OSHA], n.d., p. 2).  Many places have a no tolerance policy when it comes to workplace violence.  However, the verbiage is mainly geared towards lateral violence and not upheld when the incidents happen.  When it comes down to be a patient safety issue, patient on nurse violence is huge.  The rationale is, if a nurse is injured, staffing is often reduced, leading to job dissatisfaction, and eventual nursing turnover.

References

American Nurses Association. (2018, April 18). ANA responds to the Joint Commission sentinel event alert on physical and verbal violence against healthcare workers. Nursing World.

Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015, May). Underreporting of Workplace Violence. Workplace Health & Safety, 200-210. https://doi.org/10.1177/2165079915574684

Laureate Education, Inc. (Executive Producer). (2011). Healthcare policy and advocacy: Agenda setting and the policy process [Video file]. Retrieved from https://class.waldenu.edu/bbcswebdav/institution/USW1/201870_27/DR_NURS/NURS_8100_WC/USW1_NURS_8100_week03.html

Occupational Safety and Health Administration. (n.d.). Workplace violence in healthcare; Understanding the challenge. Retrieved from https://www.osha.gov/Publications/OSHA3826.pdf

The Joint Commission. (2018). Physical and verbal violence against health care workers. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf

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