Relief

I'd been at my new job as Clinical Program Coordinator for a hospital system's stroke program for nearly three months before I recognized a feeling that had been building for some time now.


Relief.


For the longest time I couldn't imagine doing anything but bedside care. Now, I can't imagine going back. After all, there is nothing I can do as a function of my current job that will endanger a patient's health, a patient's life, or my nursing license. I never really grasped what a burden that was and how tired of it I was becoming.

It wasn't something that was at the forefront of my mind whenever I clocked in to do bedside care. Well, not unless I was being floated to someplace like Orthopaedics or Spine: someplace I felt like I was practicing outside my competency. It's not a whole lot different when trying to run a floor short handed, or there are other confounding circumstances that kept me from giving my patients the best care I could.

When I was younger, I either wasn't fully aware of that burden or I was just better able to bear it. But years pass, times change, I've changed. I don't know how some of my colleagues continue on doing 12 hour nights in bedside critical care, for years longer that my 23 years. Perhaps it's a sense of duty, or feeling they have no other choice, or that is what they love about nursing. I already knew my care was degrading, and I had to get out of bedside care before I seriously hurt someone.

And it wasn't just my patients I was worried about injuring. In order to sleep during the day and function at night, I was resorting to unwise courses of action which I will not detail here. I can, however emphasis with Michael Jackson's desperation for sleep, and the lengths one can be driven to to get it.
But it was more than that. In the autumn of 2009, I was off for 3 weeks with the swine flu, and another three with plantar fasciitus. Fortunately, I had more than enough sick time built up. But it reminded me how vulnerable I'd be if I suffered, say, a broken leg (or worse, a broken back). How would I take care of patients? That's about the worse way to have to embark on a career transition, with the question of "transition to what?" not even yet asked.
I can do my job with a broken limb, even if wheelchair-bound. Not having to depend on my body in the same way is an immense relief. Of course, that doesn't mean I feel no obligation to lose the 10 pounds I gained since changing jobs, and then some. I want to enjoy this relief for as long as I can.

I don't regret the burden I carried as a bedside nurse, it was part-and-parcel of a career I continue to find rewarding on myriad levels, and helped me remember that what I was doing was important: "just a staff nurse" is a semantically null term. But it also became a burden that I knew I could not bear for much longer. It was time to pass it to younger and stronger backs.

Sometimes, you don't realize how heavy a burden was until you at last set it down.

The Face of the Vorlon

"When you have doubt of your course in life, you need only look in the face of a Vorlon, and all doubt will be erased forever."

- Dukat, Babylon 5: In the Beginning

While it would be overstating that all doubt has been erased forever, a great deal of it has been relieved recently.

I knew it was time to leave bedside care, but I had lingering doubts as to whether taking the role of Clinical Program Coordinator for a Pacific Northwest hospital system's stroke program was the right move. What is my role? What to I bring to the table? What is my, for lack of a better word, mission?
Just a couple days ago, I "saw the face of the Vorlon." There's an initiative to get all the system's policies, procedures, and protocols "reformatted" into a consistent form. I figured this would be a good task for me to start with: it would allow me to become familiar with the policies and protocols, and it was work I could do without having to hit the ground as a "stroke expert."

Right.

The stroke program was originally the fiefdom of the program medical director and one nurse. The programs policies and protocols had to make sense to them and they were the only ones who needed to be able to explain it. Well, the one nurse retired, and her replacement has been trying to pick up the pieces. As we've been examining the various protocols, we've discovered a lot of vague wording, inconsistency, and formatting that is more complex than necessary.
The nurse education materials aren't much better. The stroke program's clinical nurse specialist and I have discovered that part of the reason neurological checks aren't being documented correctly on many stroke patients is because of conflicting education materials.

Aye-yi-yi...

I know my strengths: analysis, systems thinking, tenacity, and a touch of OCD. The policies and protocols have to be, in themselves, a cohesive system in support of the larger system of the stroke program. Same goes for the nurse education information and materials. They aren't.

It looks like my role will be to make them such. I can't help but think that improving the policy and education infrastructure of the program will lead to better compliance and therefore, better patient outcomes. That may well be the OCD talking, but I believe it anyway.

The uncertainty of what I should be doing each day when I go in to work has vanished. I know what I need to do, and what I most quickly need to know. The doubt is gone.

Besides, I now have a purpose for which I can leverage my OCD. Since I'm no longer doing bedside critical care, I needed something!

Transitioning

After 23 years night shift bedside-care ICU, it was time for a change. I wasn't sleeping well enough during the day, and staying adequately alert through my 12 hour shift was becoming a dicier proposition. Worse, direct patient care was becoming less fun, less interesting, and less personally fulfilling. I didn't like how jaded I was becoming, the person I was becoming, and the nurse I was becoming.
This discontent was augmented by my fifth, and most miserable, Minneapolis winter. I've heard Garrison Keillor wax lyrical about Winter in Minnesota: its austere beauty, its realism...it reminds me of C.S. Lewis's Screwtape describing Hell. I don't think it's a coincidence.
So after much searching, several applications, and a handful of interviews, I'm now in Portland, OR, helping a multi-hospital system run its comprehenisve stroke program. It's a substantial transition. one that, on many levels, is still underway. On others, it has yet to begin.
Patricia Benner's seminal From Novice to Expert is very much my lived experience, except right now, it's going the other direction. I went from being an expert bedside critical-care nurse to being a novice clinical program coordinator. It's much like wandering around a blacked-out sports arena with just a flashlight to light my way. I have no idea what the entire interior looks like or how to make a contribution in its operation.
My role is very different from direct patient care. Instead of working in a system, I'm working with a system and on a system. A daunting challenge, especially in that I only marginally understand the system. So my "sports arena" isn't laid out like any sports arena I've been in, and with my "flashlight," I can barely guess how it's laid out.
This is on top of re-learning how to live in an apartment and find my way around Portland (a really cool city, by the way). My wife and I are building new relationships and learning how to live with each other with this different schedule. It's a little more difficult for her to "nest" in bed with her knitting until the wee hours if I'm there having to sleep.
But it will all work out. We both want this change, and we tried to "be careful what we wished for." We have confidence in ourselves and each other that we will meet the challenge of this transition, and prevail against it.
That doesn't necessarily make it any easier or any more fun.

WWDD?

WWJD poses a worthy question. “What would Jesus do?” effectively gets to the heart of “the big issues”: poverty, justice, conflict, and other major social and moral questions that face us individually and collectively. The answer we come to when we ask “What would Jesus do?” may not be a comfortable one, but it is likely to be morally sound, wise, and kind.

However, not all the questions we face in life are carry moral weight or social importance. They are not questions of “What is right?” but rather “What is effective?” How do I get the fine cat hair out of my rug? How can I be sure everyone is doing this calculation the correct way? Where in cyberspace should this document “live.” To answer such questions, a better acronym might be WWDD: “What would Dyson do?”

Our cat, Caesar, has a very fine undercoat which he is constantly shedding. These fine fibers interweave and trap themselves in our rugs, are difficult to dislodge by ordinary means. That all changed when we got this Dyson vacuum cleaner. It pulled the white cat hair out of the black rug so thoroughly, the rug changed color. My wife and I were sold.

What would Dyson do? In the commercials, James Dyson speaks of “solving the obvious problems.” But there’s more to it than that. You also look at all the “moving parts” involved in the solution, and carefully reason through how to make them work best. But how does this work in everyday problem solving?

One feature of Dyson vacuums is that they are bagless. After all, you never knew quite a bag got full, changing the bag was always a hassle, and you had to keep a supply on hand. A clear, bagless container solved these problems. Where I work, we occasionally have to use a complex formula to measure how well someone’s heart is pumping. It was all written out in standard mathematical format, and people would have to sit down with calculators to come up with a value that provided critical clinical information. What could possibly go wrong?

The obvious solution? All the computer workstations had Microsoft Excel installed. I created a spreadsheet that allowed the nurse to plug in the appropriate values, and presto, the cardiac output would be calculated, consistently and error-free. It is now available on all the cardiac ICU workstations.

The choice of a clear, bagless collection chamber creates its own issues. How do you empty it, as easily and comfortably as possible? The solution involves two buttons. The first releases the chamber from the vacuum. The second, accessible only after the chamber is released, opens the trap-door bottom to empty the chamber. No contact required. I do this directly in the garbage can outside.

Recently, I got to sit in on a meeting concerning paperwork flow. A hospital's (not where I currently work) Ethics Committee is occasionally consulted about "therapeutic interruption of pregnancy" (aborting a non-viable fetus) and must approve the procedure before before the patient is actually even a patient. While this avoids the regulatory hoops and political stigma of becoming an abortion clinic, it created other problems. How do we track the information in the hospital's electronic medical record system? After all, the patient might have the procedure done elsewhere, or not do it at all.

There was talk of creating a “ghost chart” to contain information, to be "resurrected" when the patient was admitted. But in that the patient wasn't even a patient of the hospital, and might never be, they could end up with a number of these "ghosts" haunting them. These situations were also relatively rare: maybe a dozen a year. Creating a "ghost chart" seemed a cumbersome way to address the issue.

Then, they remembered the patient already has a chart, back at the referring doctor’s office. The Ethics Committee’s decision would be sent back to the referring doctor, and “live” in that chart. If the patient is admitted, the chart from the doctor’s office, including the Ethics Committee decision, would follow the patient over. No virtual chart needed. All the moving parts fit together, and do the job elegantly and effectively. It’s what Dyson would do.

Patient care has a lot of "moving parts," and not all of them (and sometime frustratingly few of them) mesh well. What would Jesus do in approaching these challenges? Aside from approaching the challenge with humility and faith, I find it difficult to come up with a useful answer. What would Dyson do? Identify the problems and solve them. Look critically at the moving parts, and thoughtfully arrange them to best effect.

When trying to do what’s right, it would be difficult to better than ask, “What would Jesus do?” Not all questions are about what’s right, some are about what works. In such cases, the more salient question may be, “What would Dyson do?”

Rethinking EBP

"Evidence-based practice" and "best practices" are lionized as the key to improvement of more or less everything. To an extent, that claim has tremendous validity. There is also a Dark Side.

As an evidence-based practice fellow, I've discovered that if the question is at all complex, figuring out "what the evidence says we should do" is a labyrinthine process that can lead to no real answers. What does the evidence say? Who decides? In my effort to determine the best evidence-supported strategies for preventing patient falls, some of the most scholarly of the research demonstrated the most glaring misunderstandings of such concepts as "risk factors" and the conditions needed to truly test the "specificity" of a tool.
"Best practices" have a similar shortcoming. Often, such practices are "best" only in proscribed circumstances, which may or may not have anything to do with the problem you're trying to solve or the process you're trying to improve.
Both approaches are also time-consuming, whether they yield useful results or not. In the increasingly dynamic environment all industries (including health care) find themselves, is the expenditure of limited resources in such endeavors an investment, or merely a gamble? Is there another way?

Perhaps instead of chasing the horizon or falling into perfectionistic paralysis trying to identify "best practices," we can make faster progress seeking and implementing better practices:

• Is there something, however small, you could be doing better?
• Does an alternative have research supporting it, or at least make prima facie sense (sometimes, that's as good as it gets)?
• Instead of sweeping, large scale changes, can changes be made incrementally?
• Is there a story that supports the change?

This last item is important: there must be a compelling story for a change to be supported and new patterns established. Data and facts do not change minds, the truth doesn't speak for itself, nor does it set you free. There needs to be an emotionally engaging story to sell the change, no matter how much research supports it.

Evidence-based best practices have a well-earned place among quality improvement techniques. However, progress and improvement can also be impeded by the perfectionistic pursuit of that one best practice, or endlessly delayed while evidence is gathered and analyzed, by which time there is new evidence to be considered. Identifying and implementing "better practices" may better allow progress to be pursued with agility and alacrity.

Loved to Death

There is currently a lot of debate around how or even if manufacturing processes such as LEAN and Six Sigma "have any place in health care." The question seems polarizing, with both opponents and proponents providing more heat than light. As if global warming isn't bad enough already.
The problem isn't so much a particular technique (or dare I say, fashion), it is the managerial propensity for falling in love. It's happened before.
Remember clinical paths (care maps, critical paths)? They were going to be the saviour of health care! For a while, they showed some promising results. Patients got better and more timely care. Outcomes improved. Across-the-board job satisfaction of health care workers improved. The costs of providing care decreased.
So what went wrong?
One of the truths about any tool is that it works well for a specific and proscribed number of tasks. This is as true for clinical paths as it is for screwdrivers. You might be able to adjust a Philips-headed screw with a flat-blade screwdriver, but using a Philips screwdriver would yield better results and be easier.
Similarly, clinical paths worked beautifully for some specific diagnostic or procedural group: open-heart surgery, joint replacement surgery, treatment of community acquired-pneumonia. Steps that improved patient outcomes were identified, and systems were put in place so they weren't missed. Activities that did not improve outcomes were minimized or deleted outright. Costs went down and patients got better faster and everyone was happier.
Then someone decided that if it worked for these groups, we should do it for everyone! My standard screwdriver drives standard screws so well, let's use it to drive other screws! And drive nails! And saw wood! And (this is critical) think of the money we'll save!
That the proposition made no sense whatsoever was somehow overlooked.
You can imagine what happened. Clinical paths work, and work well, for those patients who are likely to have a fairly standard hospital course. If the diagnosis, patient response, or complications make the course in any way non-standard, the patient "falls off the path." This isn't necessarily bad, but the tool is no longer useful, and all the improvisation or wishful thinking or watering down will make it so. When one hospital I worked at announced the goal of having 90% of the patients on clinical paths, I knew they were doomed. Some of the paths became so generic that it met the stated goal, but did nothing to improve patient care. Make that "less than nothing": it diluted the power of a once-useful tool, created a paperwork distraction from the real work of patient care, and created the false dichotomy of "it's either useful for everyone, or it's useless."
No tool is useful for everyone, in all circumstances, ever. So instead of using clinical paths only where they were designed to work, they were used everywhere, then abandoned in frustration when the earlier results weren't replicated.
I don't know much about LEAN or Six Sigma. I've heard accounts of it working well in some aspects of health care delivery, and disastrously in others. Even at Toyota, when LEAN was first popularized, the technique was over-applied with horrendous consequences.
I don't believe these techniques will save health care. I don't believe they will necessarily destroy it, either. They, like other tools, will have their appropriate place where they will produce remarkable improvements in quality, cost control, and value.
Then, if the pattern holds true, someone will fall in love, apply the principles where they don't work, and ruin everything. How do we keep that from happening again?
I'm not sure. I think a reasonable start is to learn these systems for ourselves, so that we fully understand their appropriate uses. We also need a healthy level of skepticism: no bullet is magic. Any approach in current favor should be critically appraised with at least this question: "What circumstances or processes do this technique's developers recommend it not be used for?" That question should have a meaningful answer, and that answer should be believed.
We all need to be willing to try new tools, as there may well be something better out there. We also need to understand those tools, understand their appropriate use, and use them correctly.
It's something we aren't particularly good at.

Defining "Safe"

As members of the Minnesota Nurses' Association file to their respective polling places to vote whether to ratify their new contract, they are faced with the reality that safe patient care in general and "safe" staffing levels in particular are going to be a complex and protracted endeavor.

However, before they even attempt to engage their respective hospital administrations in a discussion about patient safety, nurses need to arrive at their own, specific definition of "patient safety."
Of course, everyone wants patients to be "safe." Do all parties mean the same things by the word "safe"? Corporations, most recently Toyota and British Petroleum, are notorious for a more elastic definition of "safe." Classically, corporations will comply with the letter of the law, but no more. Any additional safety initiatives are closely monitored, and are considered a success if they save at least as much money (in the form of litigation fees, fines, settlements, and so on) as they cost. If they don't, no matter how much improved safety is realized from the program, it's "financially unsupportable."
Nurses have a more stringent definition...somewhere. It's difficult to define patient safety, and tease it out from such phenomena as optimal care or a busy patient assignment. Does it necessarily follow that not getting a meal break means patient safety was at risk? Some say yes, some say no, some simply aren't sure.
Moreover, is "safe patient care" enough? I would contend that safe patient care is a component, but not the totality of either effective patient care or optimal patient care, both of which beg their own definitions. When the best I can say about my shift is, "I gave really safe care," I'm trying to console myself, not congratulate myself.
In my evidence-based practice research around patient falls prevention, it occurred to me the interventions to prevent falls broke down into three categories:

1. Decreasing the number and intensity of risk factors.
2. Supporting, improving, and increasing the patient's adaptive behaviors to prevent falls.
3. Interrupting behaviors that increase patient falls risk.

It occurs to me that safe patient care requires similar capacities from the caregiver. Specifically:

1. Identification of risk factors, events, or processes that increase the exposure of the patient to harm.
2. Intervention to decrease or eliminate these risk factors, events, or processes, thereby decreasing the risk of harm to the patient.
3. "Rescuing" the patient from emergent harmful situations.
4. Adequate resources (personnel, equipment, training) to carry out these safety activities.

I can't even guess if this is a workable definition, or even the foundation for someone else to develop one. I do know, however, that if we can't clearly define what we consider "safe patient care," we can't measure it and we can't effectively advocate for it. It requires profound limberness of logic to insist that because you can pay for whatever damage you've caused and no one was hurt (much), you're a safe driver. Unless we have a definition with more veracity, this may well end up stuck with this one.

Safe patient care is not excellent patient care, but excellent patient care is safe patient care. Until we have a standard to which we can compare the caregiving circumstances we face, we will be unable to truly know what is required to provide safe and excellent patient care. And odds are, we'll end up providing neither.