Nurse Leadership

I have just come to the end of teaching an online class on nurse leadership, it is a class I have done a few times now and its good to deal with a familiar syllabus and understand upcoming assignments better.  The course content has stirred in my thoughts about nurse leadership and a discussion with students that is new and energizing.

I look back at the nurse leaders I have been fortunate enough to work with and I learned something from all of them, the good ones as well as the bad!  I have had leaders who have had a transformational democratic style and those who were undoubtedly autocratic dictators!!  I remember one of my first student nurse clinical experiences on a surgical unit in a small mining town in Northern England.  The matron on the floor had trained in the military..enough said, you could eat off her floors.  She ran her floor like a D Day reenactment!  It was intimidating, we asked very few questions but somehow learning took place and the patients were cared for beautifully.  I do not remember one post op surgical infection, no-one went a day and a half without pooping! and those beds were made with crisp sharp angles on the corners!  But I also took from that experience I did not want to be an intimidating leader, I wanted relationship, to be a mentor, more of a coach and that is what I have based my hands on and teaching career on in nursing.  I also remember my first job as a graduate nurse on a busy Neuro Ward in Oxford, England.  The matron had an open door policy, wanted to know all her staff and their husbands, wives and children.  We socialized outside of work, it felt like family, community.  It was a gift as a new nurse to be able to make mistakes in a safe and supported place, I learned so much and still think back on that time with fondness.

The syllabus for this leadership class also presents the students with a survey of how politically savvy are they.  Very valuable tool, are they connected to the staff as a community or do they operate in an isolated way?  Is their voice influential and is their leadership style appropriate for the environment or do they need to consider changing it?   This survey led to much class room discussion on who we are, why we are the way we are, and what is the cost benefit/loss of all of it.  To be influential, powerful and effective as a leader I do not think you have to have the loudest voice, strongest personality or the most letters after your name, although I do think education gives you greater credibility.  But I do think you must be authentic, have incredibly high standards of nursing care, treat patients, colleagues of every color, rank and skill with respect and keep working on growing professionally and personally.

Yet Another Nursing Dilemma

Of course as nurses we often have daily dilemma's because caring for people can be messy, does not always fit into any ethically correct template, all those variables of people, family, diagnosis, living arrangements, emotional state, motivation or lack of it play into the outcomes of the nursing plan I devise at admission.

I have this patient, lets call her Alice, she lives with her mentally challenged brother who is high functioning but certainly not capable of making any of the household decisions.  Alice has COPD caused undoubtedly from her addiction to cigarettes.  She is admitted to the hospital on average once a month due to an exacerbation of COPD, is on 6 liters of O2, still smokes at least a pack a day.  Alice has type 2 diabetes caused undoubtedly from extended use of steroids for her COPD and an addiction to fast food, she is low income and so I have organized meals on wheels to be delivered every week, she is completely home bound so I also organized a food pantry to deliver to her every week.  She orders out fast food to be delivered daily.  The end of the money always comes way before the end of the month.  She cries and cries by the 20th of every month that she has no funds to feed her or her brother even though the fridge and freezer is full of donated food she does not want to eat.  She is estranged from most of her family due to her unhealthy lifestyle, they are all exhausted with trying to help her, so Alice is basically alone with her brother.

Alice has pulse ox consistently in the high 80's on O2 and her blood sugars are regularly over 250 in the morning if she takes them at all.  There are many other diagnosis including colitis, depression, fibromyalgia, cataracts to name but a few.  She sees her physician monthly (when she is not in hospital) but he has all but given up on her because she never follows instructions.

For the past 18 months I have been seeing Alice, twice sometimes three times a week to monitor her physical status and teach/encourage her on smoking cessation strategies, compliance with a diabetic diet, and most of all O2 safety in the home (I am so afraid she will blow up her and her brother when smoking during O2 use).  Nothing has changed, if anything her physical condition gets progressively worse.  And in the midst of all this, we became friends, I like Alice, she likes me.  We start and end our visits with a hug.  She has my cell phone number memorized (not always a good thing!).  And so I continued to go and attend to her needs, and I know her physical therapist was working as hard as I was to help Alice reach her potential, all to no avail.  This week I realized I had become another one of her enablers.  It would have been easier if Alice were obnoxious, verbally aggressive but she is not, she is sweet and grateful and has no interest in participating in her plan of care.  I am no longer helping her in anyway.  So after a case conference with the team and her family doctor this will be the last week I will see Alice.

She cried when I told her, she scowled when I honestly told her why, she does not want to change but she does not want to lose her team.  Unfortunately when Medicare is paying all the bills you cannot have it both ways.  Above all that I realized Alice needs a new team, fresh eyes and she also needs to see accountability in her poor sick addicted life.  I am torn about this decision as I am certain it is the right direction to go but I also struggle with Alice's perception that I am abandoning her.  I continue to explore the benefits of keeping a nurse patient relationship therapeutic, sometimes its not as easy as the text book says it is!

Summer.....what Summer

So great plans and all that.  My summer was supposed to be quiet and serene, lots of time for getting through that pile of books in my study and do some writing, including updating this blog on a weekly basis.  What happened?  Life happened.  We spent the beginning and the end of the summer travelling to Barcelona, London, and later South Carolina and Colorado and thoroughly enjoyed all of it, especially Colorado, there is something about being in the mountains that speaks to my soul, restores me a little, we all need that every now and again, especially in a high burnout profession like Nursing.

I continued with community nursing which had its very busy weeks covering for staff who were gone on vacation.  I had both interesting, sweet and challenging patients and some very hostile relatives.  I continually tell myself, their aggression is not really about me, its more about the frustration of their situation.  For an elderly patient who is facing end of life issues, a helpless relative can feel powerless and this can come across as dissatisfaction of care to the health professional in the line of fire (literally!).  Even though I know all this after several "not so nice" rels this summer I admit to it all getting a little old, being shouted at and second guessed several times a week.  But we soldier on, the hands on care is still the most magical part of nursing for me.

I also continued with my online teaching commitments.  This summer I have been coaching a leadership class and thoroughly enjoying it.  These young BSN students see themselves as novices even though many of them have years of clinical experience.  But the online education experience is a wonderful medium to exchange powerful ideas, lively discussions, solve issues hypothetically through PowerPoint presentations and develop a base knowledge that will hopefully lead them onto successful leadership positions.  All I really have to do is facilitate and grade 60 papers every weekend (groan!), all done at home by the power of my laptop, my perfect kind of job.

Just when things got to August and looked like I may have a month of breathing space before my semester starts again for my traditional teaching job at a Philadelphia University we met this guy....

I really was uncertain about doing the dog thing after losing our beloved Golden Retriever in April.  However one particular weekend when I was missing him so acutely my husband put me in the car and took me to a pet adoption at a local pet store....and there we met Toby.  It was love at first sight.  An adorable choc lab/pointer mix.  Loves to snuggle, chew cell phones and TV remotes.  He is especially fond of the 3am pee followed by a snuggle in bed.  And so I am now walking the neighborhood at 7am/pm every day, chasing him around the house with my carpet shampooer (forgot how much work potty training is), trying to persuade him not to eat the cat daily ( I secretly think the cat quite enjoys it!).  Exhausted and enjoying every minute of him

Faculty meetings have begun, planning and organizing a new semester is ongoing, I am ready to roll with whatever fall brings me and looking forward to it.

How was your summer?

Global Nursing

I was recently in London and attended a conference titled, Nurse Led Clinics.  It was a fascinating day with many excellent speakers.  As an advanced practice nurse who runs her own company and loves being my own boss I was interested to see how this concept was being developed in the UK, my homeland but one I have not worked in as a health care professional for nearly 20 years.

It seems the National Health Care Service is moving in the same way (relatively speaking) as the US, in terms of need for accountability of costs, tendering of services - which means there is no reason why nurses, physical therapists and others cannot form their own groups and bid for contracts.  It is an exciting time of change in the UK.  However, I appreciate not being a part of the NHS anymore it is probably very frustrating to live with these changes.  What is refreshing is that the UK system is still a service based industry whereas the US health care system is very much profit driven, sometimes quality of care gets lost in both systems.

I see a two tier system developing in the UK, where many people now have private insurance through their employers and prefer to get their point of service care, elective surgery and treatment through the private route.  Does this make the free NHS suffer, not sure, have not had enough exposure to that lately to make a judgement.  However, it does not seem that much different to the US system where we have the medicare/medicaid population, the totally uninsured and the rest of the nation.  It certainly is a tiered system where there are different levels of quality care depending of what coverage you have.

It was not all work though, I thoroughly enjoyed Barcelona, especially the flamenco festival that was taking place right outside our hotel.  It was lovely to see London draped in Union Jacks in anticipation of the Queens Jubilee (God Bless her) and the Summer Olympics.

Now back to the reality of home.  Have started double duty in my community health class that I teach on line, balancing 50 students instead of the usual 30!!!  I just keep saying to myself "Angie, you got this, you so have this!!"  Community health work has slowed down a little this week for which I am grateful.  I have not taught this class since February so I am taking the extra time to catch up on readings and go through the syllabus in detail.

I feel like I am on a new summer schedule and it feels good, getting up late, lazy breakfast, check in with my students, do a few visits, wander around my beautiful yard dead heading and pruning and then back to check in with my students later on in the day.  I could get used to this, very satisfying.

Next trip is to South Carolina in July and potentially a trip to Colorado in August. Life is good, long may it continue.

End of One Thing, Beginning of Another

The spring semester has finally been completed.  I should not be shocked at how much I learn from the students, but I do and I hope they learn much from me not just about pediatrics but about the art of nursing.  I think I have said before I am not just interested in developing these young adults as nurses but also as people.  The time I have getting to know them, learning their stresses and their joys brings a great deal of satisfaction to my teaching experience.  Every group seems to have its own "personality".  This group was more nervous than previous ones but very personable and teachable, they made me smile and though some of them lacked confidence (unduly) in their clinical skills their people skills were excellent.  I was very pleased the way they reached out to the children and family on the floor.

One of the most difficult cases we had this semester and one many of them spoke of in their reflection paper was the admission of a child who had been severely abused and showed evidence of several old fractures.  The students were quick to judge the parents/caretakers of this child, and I too struggled with the pain this small child was enduring.  But it was a lesson in tolerance and practicing non-judgemental care to the whole family.  While child abuse for me will always be without question inexcusable we have to remind ourselves as practitioners that we do not know the whole story and we must suspend our strong emotions so they do not get in the way of the care we are called to give.  I am thankful for Social Workers and DHS who do the hard work in these situations.  Needless to say this child received a huge amount of attention by all students and staff while he was in our care, we managed to get a few smiles out of him.

The rest of the semester was uneventful, we had our fair share of asthma, bronchiolitis, pylonephritis, basic stuff but excellent to teach the fundamentals.  I am excited to have just found some wonderful 3D applications for my ipad of the kidney and lungs that will make great teaching tools next semester (thanks hubby)  Its always easier to visualize the anatomy and explain the disease process rather than just verbalize it.

Exams and evaluations are complete, even had my students over for a celebratory afternoon tea which I loved so I intend to do that again.  Whats next for me.

A summer of work but in a different way, I intend to teach two classes simultaneously online which will be busy but hopefully done from the sun trap called my deck.  Of course I will continue with my community nursing but the goal is to gradually scale back and do more teaching on line and in the traditional setting, we shall see what future opportunities bring.

At the moment we are having a sad time in my house, mourning the loss of my dear 13 year old Golden Retriever who we had since he was 8 weeks old and was as much an integral part of the family as the kids.  Medicating my grief with some travel, about to tag along on my husbands business trips to Barcelona, England and South Carolina to name but a few.  When the kids leave for college and the animals start dying we find ourselves in transition again, I want to embrace the change sometimes it just comes a bit quick!!!!!

Weekend On Call

About once a month I do the on call schedule for the nursing agency I contract with.  This weekend was my turn on call and it was horrific.  I spent the weekend looking at stinky butts and feet with no toes on!!

Enough said.......just wanted to get that off my chest.

Ageism and My Misconceptions

So, this week I started teaching a new online class on aging populations.  It is an extreme change for me after being so involved in pediatrics for the past 20 plus years.  However, following my return to community health I have seen a mainly an elderly population and have found I absolutely love this demographic.  Anyways, week ones topic was ageism, what is it, are we guilty of it and how do we deal with it.

First of all the students were required to take a self assessment survey to judge their baseline prejudices and knowledge of the elderly.  I took the survey myself, found not only did I hold many prejudices about the elderly but I also assumed to be true many myths and did not do as well as I thought I should....a little humbling moment for Angie.  For example, I am a huge offender of calling the elderly sweetie and honey.  Now I have to admit that on a busy day I sometimes do this if I cannot remember a patients name, but still it must stop, a person is a person (Happy Birthday Dr Seuss) and they deserve to be addressed correctly.  On first meeting I do try very hard to greet the new patient as Mr or Mrs So and So but after that all bets are off.....I will make a better effort.  

I assumed that pain was a natural symptom of aging, not so, pain is a symptom of disease and should always be assessed and evaluated.  Here I am Miss Self Righteous Pediatric Clinical Instructor preaching to my students every week that pain is what the patient says it is and all children should be assessed with the appropriate scale.  Going to do a better job on that one too!

I also incorrectly assumed that the elderly get more religious as they get older and deal with change better but apparently this is also not true.  When I think about it I am getting less enamoured with organized religion and less inclined to change my present situation because I have about as much I can handle right now so why should aging be a catalyst to liking religion or change anymore than you do when younger.

I can see how this course will challenge me on many levels but will only help me in my scope of practice.  The discussions are already lively and challenging, a good bunch of students.  Looking forward to the next 5 weeks of learning and facilitating all I can.