Learn to Speak-UP

The hospital is said to be one of the "toxic" work environments a professional is exposed to. Yeah, "toxic"- we hear it in the laboratory, in the emergency room, in the wards, in almost all of its corners. I came across a discussion forum and even the "call center industry" is quite adapting the word. toxic to its work vocabulary. (Is it due to the fact that some of this industries are absorbing the "nurses" who are in the long-list of waiting their turns to achieve that American dream-"deferred"...)

Take this scenario as example,
The patient who was stable the whole day shift suddenly alarms you with its ailing vital signs, in a few blink of an eye... he goes into shock, you responded like a superhero directing almost all the necessary scene. Your doctor has been called but "darn" he can't fly coz he's attending to a set of patients at the ER. You felt you are doomed, so using all the theories possible, you magnificently done all nursing matters, then the doc arrives... instead of going to "attend" to the dying patient. He continuously fires at you with his foul mouth while you are reporting the measures you have done while doing another multi-tasking to assume the needs of the "master".

He mentions,
"Increase oxygen, give this shot...", then he writes the order. You are still monitoring the patient then the machine falters, you want to scream. You did all your resourceful ways to manage the patient, then he revives. BRAVO! You don't feel good not because the patient has been revived but as you see yourself in the mirror, you have come to realize that you lost your dignity in just a blink of a second.

You wanna release your concerns to a standard "nurses conference". The head nurse is sticking to an agenda that, "Hey we will discuss only the vacation leaves, Christmas is approaching. No buts!" This has become the usual scenario. You tried to convince your colleagues that some of the system are taking part of the difficulties at work, you want to simply end a cycle of inefficiency: when will the new machine be delivered, do we have enough tools and emergency medicines, the telephone lines are scratchy, the charities, the annoying mistreatment of other members of the health team- you basically can't open your mouth because someone just put a warning on the term called, VIP. You're pissed most especially when the other colleague just said her piece of negativity, "It's no use, nothing will change"... A sign of powerlessness.

Nurses are taught to prioritize the patient at all times because the patient is the center-fold beneficent of such care we render. Who takes care of the nurse? the doctor? What I'm trying to say is the idea of speaking up; it should not be impeded for the nurses own release of that "stress". We hear stuff like "verbalization of feelings" in therapeutic communication but the idea should also include the carer. Allowing the nurse to be himself, be human in the work environment should not be a detriment to the institution. The administrative officials may interpret this as "activism" but the core is to basically bring out the best in each of the carer and other professionals. No one dares to cross the administrative level because of the unwritten protocols that has been embedded in the work environment. So as the "silence" goes on, the cycle can be destructive to nurses as an individual and collectively. A nurse should be allowed to complain in order to give rise to work-related issues. This is not about nurse-centered approach activism but this is all about for patient-centered advocacy that requires doses of solutions that is needed for the creation of changes in the system needed.

Certainly, how to avoid that without facing a threat of getting fired from service? Can a nurse be threatened just because he simply informed of cheaper choices on where to buy anesthetic agents wherein his core principle is "just to inform because it is patient's right"?

It takes a collective effort to really materialize those changes. It may start from one work area to another.

In an article by Diana J. Mason, PhD, EIC of American Journal of Nursing, she wrote the following in which the article discussed about "nurse's powerlessness":

1. Identify the most pushing challenges in the immediate environment.
2. Initiate dialog with colleagues to find solutions to the problems.
3. Remain actively involved in the solutions until they're working.

No one should be fired for being assertive in speaking out nurse's concerns, one should be allowed to speak and respect, even when angry...

When I pricked myself Ouch!

When I had a "return demonstration" for venipuncture for drawing blood using various techniques in laboratory technology, our clinical chemistry professor demonstrated a "recap" method using a single hand after drawing blood for laboratory analysis. The one on one pricking (we would have partners) made everyone so excited because this is one of the "basic" skills that a laboratory technologist should develop as he or she progresses with the course. Yes, we were taught about the Anatomy and Physiology on where to draw blood but we were not prepared psychologically for the implication of being pricked by the needle in which the professor has no concern about. (Neither did he stress on blood-borne diseases after being injured with a needle or sharp. ) Maybe, he assumed that "we are taking the course" and we are expected to have a high tolerance to such procedures because every now and then, we will be dealing with it for the rest of the practice. I was a "sick" child as I grew up and the hospital has become a "traumatic" place for me as I recall "invasive" and sad memories of being hospitalized. I almost died with German measles way-back in the 80's. Yet, ironic as it may sound, I still chose the path to join the health care profession because of my inclination to science and medicine.
And so, I know how painful the needle prick is so as I learned various techniques in "injections" for the purpose of diagnosis, drug administration and intravenous therapy, I have been very keen in assuring patient, explaining them of the nature of the procedure and the expected outcomes of such procedure/s not just because it's their "rights" but it is a way to alleviate anxiety. Sometimes, the procedure has to be repetitive as in the case of patients with diabetes wherein a practitioner pricks to test blood glucose then another one for insulin (depends on the glucose result). Should there be patient empowerment (wherein patient \takes part of his glucose meter and pricks himself would be a helpful for both patient and provider) then dealing with the problem is a lot more easier.
Yet, the key to understanding pain is to have also a personal experience of the pain itself. I am more concerned now with the fact that most health care facilities have not yet tapped the needle-less equipment or safety lock syringes or shielded needles for delivering most drugs yet so, it post accidental "self-pricking" to the health care provider Yes we trained, we are doing repetitively the procedure but I would like to oppose the confidence that one head nurse mentioned that, "We should master it even with our eyes blindfolded." Unfortunately, we are the most vulnerable in the facility, we are humans and we could hurt ourselves. During the IV training seminar, the preceptor did not stress what to do when you accidentally prick yourself with the needle. Although one head nurse always remind to use proper equipment when removing needles according to hospital standards and disposing it to appropriate containers, there was simply no "stress" on prophylaxis when the needle that pricked the provider came from an infected source. Should we tape our fingers to protect ourselves through wound opening, should we use gloves (which is not always present in work area)- I would like to say that it is unfortunate that this frequent incident- when nurse prick themselves accidentally and there's no standard procedure on what to do that is part of the policy of such facility really gives a heightened stress level to the nurse. Basically he or she is thinking about the pain and the possible infection that he or she will get. The absence of such policy endangers nurses and is psychologically unhealthy for their well-being.
In an article, " Needlestick dangers for nurses neglected", Nursing Times author Helen Mooney identified significant statistics regarding needlestick injury in 2008. It revealed ,"falling confidence among nurses in their employers' level of support after a sharps incident. Just under 70% felt their employer offered them adequate support". (see link for details).
I agree with Kim Sunley on "Being injured and going though psychological impacts that the incident does not develop into something life-threatening is underestimated". Yet, how many of our local hospitals really have a "sharps policy and a protocol to give advice to their employees with regards on what to do after the injury and prophylactic management? What about student nurses and trainees? Are they covered of such protocols? I can see that having a training on safe needle use is not enough and access to safer needle devices are still difficult to achieve since due to many factors but how long can nurses keep up to this kind of work environment where the risk is high and reports have not been properly documented?

When the Abbreviation Becomes the Killer

The patient chart is a very important document in the facility that serves as a communication tool on the whole course of the patient's care. It is a vital document that allows us to facilitate a continuous flow of care to the patient whether he or she is stable or not. When I was a student nurse, I came to realize the danger of using acronyms and abbreviations that may post great risk to the patient's well-being when Dr. Juan V. Komiya- medical director then of Lorma Medical Center stressed the importance of rather completing the "words" specifically in making doctor's order than introducing or using the shorthand that could no be understood by other members of the health care team, like the nurses (who usually carry out doctor's order). My understanding from the good doctor's perspective roots from an application of that principle in "drug orders" wherein, if not written legibly and if acronyms could have variable meanings, chances are, the nurse may have an inaccurate assumption or interpretation of its meanings. We were trained theoretically to "verify" orders from physicians when we are not sure but there are cases when these instances are not possible. Should we resort to having another supporting physician (another resident on duty) to verify the latter's order may sound unethical and may not be the standard of the facility. More so, we don't want to take much time thinking about the meaning of that acronym or abbreviation since time is essential in health care delivery, a delay may post risk again to the patient's well being.
So, as assertive as I can, I usually "ask" doctors to write legibly and with no acronyms. Luckily, the physicians who took up nursing have in any way made adjustments in the long run when they were taught the Fundamentals in Nursing practice regarding communication and documentation. However, these instances are not always the case on some training facilities. Neither they have standards posted on the bulletin boards for "allowed" shorthands. Yet, I am taking this liberty to post examples of "dangerous shorthands"...

Do Not Use	Potential Problem	Use Instead
IU (International Unit)	Mistaken as IV (intravenous) or the number 10 (ten)	Write “International Unit”
MS MSO4 or MgSO4	Can mean morphine sulfate or magnesium sulfate and are confused or mistaken for one another	Write “morphine sulfate” Write “magnesium sulfate”
Q.D., QD, q.d, qd (daily) Q.O.D., QOD, q.o.d., qod (every other day)	Mistaken for each other Period after the q mistaken for “I” and the “Q” mistaken for “I”	Write “daily” Write “every other day”
Trailing Zero (e.g. X.0 mg)* Lack of Leading Zero (.Xmg)	Decimal point is missed leading to 10-fold dose error	Write X Write 0.X
U (for unit)	Mistaken as “0”, the number 4, or “cc”	Write “unit”

While it is true that nursing is a science and an art. We can't possibly adapt the art of "texting" in making an important documentation that involves the lives of patient, the recipient of our professional service. To add, Ivy Fenton Kuhn points in an article, "Abbreviations and acronyms in healthcare: when shorter isn't sweeter" for pediatric nursing wherein it identifies the struggle to limit the use of abbreviations and acronyms in the health care community. The article also identifies the Patient Safety Issue in Healthcare involving the contribution of the use of abbreviation and medical notation's significant contribution to the statistic of serious errors and deaths. The most common problem types of its usage are:

1. Ambiguity - Abbreviations or acronyms can stand for more than one word and therefore can be misinterpreted.
2. Unfamiliar abbreviations- A reality of healthcare today is the specialized nature of individual services and disciplines.
3. Look-alike abbreviations -Throughout the healthcare literature are widespread examples of common errors due to look-alike abbreviations or symbols. These problems involve numbers as well as letters.

The article also identifies the efforts of many organizations to the development of a National Patient Safety Goal focusing on the creation of a "do not use" abbreviation list. Another is to mandate institutions to standardize a list of abbreviations, acronyms, and symbols that were not to be used throughout any accredited organization.

I have seen some local hospitals posted the list of these acronyms and abbreviations. Yet, the nurse should always be assertive when something is not clear within the orders and medication documentation.

While "The benefits of the use of abbreviation and acronyms in general documentation may appear obvious. In the case of abbreviations, they have not changed over centuries. Abbreviations and acronyms are short, space-saving, convenient and easy to use. They are simple and hard to misspell. They also may be exclusive, and therefore understandable only to a specific group of professionals (Kushlan, 1995).", it is within the bounds of professional responsibility to deal with the dynamics of this existing problem especially in a health care delivery system that has limited resources. Hence, another challenge to nursing and the rest of the members of the health care team.

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