Sick and Tired

Sick for 10 days or so, but since then I have been unbelievably tired. After school and clinicals all I wanted to do is sleep. So now it is catch-up mode for presentations and papers due.  

But it made me think, why don’t nurses get sick more often?

My sister the teacher always says she gets sick from being around the kids, and granted kids can be like little Petri dishes of germs. And at the clinic patients often say they must have caught something at work. Maybe that is true.

But what other profession depends on a business model that involves their staff having direct contact with sick, infectious and injured people. Clinics and hospitals rely on and persuade the sick to visit them. In fact they relish the various and obscure contagious diseases. Nurses and healthcare professionals must be hardy, because we get exposed to this daily. Next time I hear my sister talking about catching something at work I'll have to bite my tongue.

Gargle with Salt Water

Tried to avoid it, but to no avail. Some little virus or bacteria found its way inside of me and then kicked my ass, and left me wandering between my couch and bed for three days.  Most of it was in my respiratory system with accompanying throat pain, coughing and phlegm. The occasional headaches and muscle pains were just bonuses. 
     
The generic OTC cold and flu medication in my cupboard that expired six months ago can attest that I do not get sick often. Probably not the flu, but I will never know. Because like any good nurse I will try to avoid a doctor or urgent care visit, and self treat first. FYI, hermetically sealed expired medications still work fine. So I prescribed alternating acetaminophen, NSAIDS and Robitussin DM that seemed to keep things tolerable. 
 
However let’s be honest, the true secret weapon was gargling with warm salt water. Why does this always work so well on a throat that feels and probably looks like ground beef?

The holistic approach is still the best, because besides my salt water gargling, drinking hot tea with fresh lemon and honey was a good thing. Sympathy from others was appreciated, but not as much as a comforter on the couch, time and the occasional bowl of warm chicken soup with saltine crackers. Those things probably helped me as much as any over the counter medications. Chicken soup and saltine crackers no lack of sodium there.

McDonaldization of Healthcare

McDonaldization is a term coined by George Ritzer, when he wrote about the McDonaldization of Society. Basically, you rationalize a task and break it down into smaller parts to make it more efficient, faster and cheaper. Think of a time when a craftsman took time to manufacture a piece of furniture from start to finish. He would take a piece of oak and measure, cut, plain, chisel, border, stain and a dozen other step to make something of quality. Or a chef making something as simple as a good hamburger, there are a lot of steps. Start with good quality meat you have to grind, form and fry or grill properly. Fresh tomatoes, lettuce, onions and other produce to selected, washed and sliced. And fresh baked buns. Now think the opposite, McDonald's and IKEA. 


To increase production and profits companies turned to the McDonald's or assembly line method. A product comes down the line and a person does one thing. No thinking involved.

Most fast-food places operate this way. Frozen preformed burger, fries and food is delivered from a large factory somewhere. On the same truck comes, pre-chopped lettuce, tomatoes and onions in something that looks like a clear garbage bag. No real cooking going on, only the timers and beeps that tell the worker when everything is ready. One person takes your order and money, one person drops the fries, one person flips the burgers, one person assembles the food, and one person puts it in a bag and gives it to you. Efficiency without deviation or thinking. They even figured out how to have the customers work free, by filling their own drinks and clearing their own tables. IKEA has you pull and assemble you own furniture.

Yes assembly lines have their place and make things cheaper. Can’t imagine making millions of a cars or computers without an assembly line.
  
Healthcare has been McDonaldized. CEOs and bean counters see patients and care as products to streamline. Get them in and get them out. Like a fancy restaurant, the more times they can turn over a table during a shift, the more money made. Hospitals use beds instead tables. Healthcare has been broken down into small parts, like an assembly line of care. 

In any hospital, on any unit, you cannot avoid hearing the charge nurse, staffing and the shift manager referring to and arguing about the Bed Board. It keeps track of all the hospitals beds and who is in them. We shuffle patients in the hospital 24/7. A doctor orders a bed on a particular full unit, or a new patient needs a bed on the already full specialty unit. The shuffle begins. The people ordering the patients to be moved at midnight never see the patients. The shift manager says take the 35-year-old male on B5 to CVPCU. Then take the new admit to A3, because we are moving a patient from there to the med/surg floor. The ER patient on hold can then go to the neuro ICU, and the semi-stable ICU patient from neuro ICU can go to B5. . . checkmate. 

In the hospital, you will see every specialist there is because nobody deals with the whole person anymore. Chest pain cardiologist, a little confused neurologist and trouble peeing, a urologist or nephrologists will see you. They all specialize, one flips, one assembles and one hands you the order. Try to get a patient discharged and you need 3 different specialists to agree and sign off.


In the hospital, like Target, everything is computerized and bar coded, and we will scan patients, medications, supplies, equipment and staff.

I am in a large clinic now and it is the same. A person will check in, see a nurse for triage, see a practitioner and then the discharge person. If they need labs, pharm, x-rays or behavioral health, they can see from 4-8 people during their visit.  

In some clinics the provider has a set schedule and every 15-minutes they have to see a patient; 10:00, 10:15, 10:30, etc.  Unless you are a new patient and I am doing a complete history and physical, but those are only on Tuesdays. A regularly scheduled visit and you are limited to one problem. If you have another problem, you will need to make another appointment. You came in for a cough I will treat that. So the sore leg or mole you want me to evaluate. Sorry, no time. I will make sure it is not life threatening and can refer you to dermatology or orthopedics.

In my surgical rotations to observe, they have their own unique spins on assembly lines to make things quick and efficient.

Yes, again there are times when it is productive and makes sense to use some of these methods. However, people are not products to be flipped and hurried along to the next station in the assembly line.  

Escape Fire

I do not have the solutions, but just about everyone in healthcare knows there are problems, and we will not be fixing them anytime soon. One of my clinical rotations has me working with many homeless and uninsured individuals. Another clinical rotation has me working with an upscale rural population. None of that is the problem. The problem in this country is we do a horrible job educating and preventing disease in the first place, e.g., Primary Care.

 

http://www.escapefiremovie.com/

 

 

 

 

Patient Satisfaction Survey

When PediNP wrote about "Customer Service" in relationship to her clinic, it was something that most practitioners, from the techs to doctors, understand. We are the ones who actually touch the patients and talk to the patients and families on a daily basis.  
  
Most health care facilities around the country now provide some sort of “Patient Satisfaction Survey” after the patient has had their care. Hospitals, clinics and other healthcare services rely heavily on these surveys. Some information can be beneficial, but most of it is for the administrative bean counters and managers who never touch a patient.   

Facilities tailor these questions to their specific needs, but here is a generic form from the Department of Health and Human Services. See the flaws, sometimes these surveys look like something you would fill out after staying at the Embassy Suites or Days Inn.  When was the last time someone had a hip replaced, heart valve surgery or got a cast at a hotel or restaurant. We who touch the patients provide a different service. OK, sometimes we provide you a blanket and some mediocre food. (That is another post topic).

These hospital scores are posted online through a National database (No not Yelp). How does a survey compare a hospital or clinic that treats the under served and homeless versus one in the gated upscale suburbs? New hospital additions have private rooms and flat screen TVs, while the community hospital still has two and three beds to a room. Do you think the satisfaction score might be lower, if the patient on the other side of the curtain is on the commode all night doing his GoLytely bowel prep. Patients will provide positive or negative feedback depending on the amount narcotics given out or refused at a clinic or ER.   

Clostridium difficile and the dog

Really. This WebMD article says researchers in the Netherland taught a dog to sniff out C. difficile. Poor dog.  The dog was a 2-yer-old beagle named Cliff. Come on Cliff and C. diff, researchers are not very cleaver with word play. Anyway, when other dogs are taught to sniff out drugs and bombs, they are rewarded with tasty treats. What do you give a dog that is taught to sniff out C. diff.  I’m thinking maybe a bath.

Seriously did they spend a lot on this research, because I bet 75% of nurses with some experience at the bedside can tell you if a patient has C. diff. Even from the hallway at that particular time, nurses can make an educated guess as to whether someone has C. diff.

If fact nurses are so good we can tell the difference between the smells of a GI bleed bowel movement, C. diff diarrhea and hospital cafeteria food flatus.  Don’t try to impress your friends or family with this fact during Christmas vacation.  

Another good way to know if a patient has C. diff.  When you are floated to a new floor, look at your assignment. Yes, your patient in isolation will be the one with C. diff.   

 

 

You want me to spend my life doing what? Pick him, no pick him.

 

 

 

Labrador

Just need a break.

One more week and finals will be over. Tests are stressful, but not as much as when your instructor comes out to your primary care site to evaluate you. That is stressful. They come and sit in the corner of the exam room and say just ignore me. The patients don’t have a problem with it, but the students are a wreck. Did I diagnose it right, did I come up with the appropriate differential diagnosis and did I order the right meds and consults.

I would love to be out in the woods breathing fresh air and walking a Labrador. That is the best way to beat stress. Until then I just need to keep the goal in mind for six more months, then I can get a job and dog.

Nurse Practitioners Week

HAPPY NURSE PRACTITIONERS WEEK
November 11-17, 2012

OK I did not know there was such a thing until yesterday. Nevertheless, I guess everybody gets a day, week or month these days and thanks to Hallmark.

According to the AANP, there are approximately 155,000 nurse practitioners in the US. I would guess they work in more than 20 different specialties and areas in and out of hospitals and clinics.

Compare that to the roughly 850,000 active physicians, of which about 350,000 work in primary care. There are many different statistics from different sources about the numbers, but this seems to be the average. Anyway, for years they have been predicting an MD & DO shortage.

Nurse practitioners are not doctors or junior doctors; we are nurses with advanced degrees that can do some diagnosing and prescribing. A nurse practitioner will never have the book smarts of an MD and their medical school and residency training. However, in the wake of the aging population we should be able to work alongside and help with coming patient load that will tally in the millions.

Time management

Thought blogging though school was a good idea. However, I cannot believe how busy things have become. One day a week, we have lecture and classes for 10 hours, then 2-3 days a week we spend in clinical settings.

As a nurse, time management is a part of the job. In graduate school, I believe one of the biggest tests becomes time management. Yes, you are warned to put your life on hold until it is over and in some ways you do.  However, as an adult student that is not realistic. Family, kids, bills and work to pay those bills, all becomes a part of your time management. As important as those are, school, lectures, tests, papers, studying and clinicals are more important to get to your goal.     

How to become a Nurse Practitioner

Frequently at work other nurses ask me about my journey through my nurse practitioner program. They want to know what it is like, how hard it is, and is it worth it. I tell them it is worth it and yes, it can be hard at times. For some nurses this is just our small talk, and for years they have asked me the same questions. However, a few are really interested and I can sense they are feeling the way I was a few years ago. If they are serious, I will encourage them that this is the time to apply and go into a Nurse Practitioner or CNS program. Their next worry is about the admission process.

There are some tricks to increase your odds of being accepted. However, the first thing is start your paperwork, goal statement, and lining up those people who will write your reference letters. In the end, waiting will be the toughest part. As for the reference letters, they should be from influential people related to the health care field you want to enter. Preferably, from doctors, alumni, managers and other nurse practitioners etc, and not your nurse lunch buddy from the renal unit.

Have some volunteer or other experience to put on your application that reflects your area of interest. They notice if you are applying for a community health specialty, and the closest thing in your background is working at Kmart. That does not match your goal, so go volunteer at a free clinic or somewhere with people. Just because you might have a family, does not qualify you for a family nurse practitioner. Working with kids, seniors or under served people not related to you.      

Those are some important things, but what is really important if you want to be in school next fall and not saying I should have again for another year, then you need to be flexible.

 There are many graduate nursing programs and schools around the country, so you need to apply to more than the one in your hometown. Chances are the school closest to you is smaller with only a couple specialties, like family nurse practitioner (FNP) and nurse educator. A small school near here admitted 12 FNP students last year. Other universities will offer more areas of study for a nurse practitioner and may have clinical nurse specialist (CNS) programs. A good option if you want to stay in the hospital setting.

Then there are the large universities and institutions that offer an extensive number of specialties for nursing students. An example of these larger and better-known schools would be the University of California San Francisco, University of Washington and the University of Pennsylvania. Yes, there are other big schools like Johns Hopkins University, but I think these are the biggest and have upwards of 15-20 different specialties beyond a BSN degree. The one I attend has approximately 600 nursing students in the Masters, PhD and DNP programs. Meaning instead of 10 new students a year, they admit more like 150-200. I explained this to a nurse at work, who was thinking it would be easier to get into a smaller program. People need to apply to these larger schools.  

The other most important thing to increasing your odds to being accepted at a larger school is to think outside the box. Having talked to faculty and individuals working in the admissions office, do not be like everybody else and think specialty.  

Your admissions office might be able to give you hints, but the most heavily applied to areas in my school and probably most are of course the hardest to be accepted, these include:

Family Nurse Practitioner: I understand this is by far the most heavily applied to area and hardest to get into. For some reason everybody wants to be an FNP, they remind me of the old family practice doctors and they treat just about everybody. This was not for me, because although I like kids, I do not want to deal with their parents.

The Nurse Midwife/Women’s Health Nurse Practitioner

Pediatric Nurse Practitioner.

Acute Care Nurse Practitioner; most schools require at least a year or two of ICU or ER experience to even apply. Even so, they get more applications than spots available. Most of these student want to stay in the hospital setting.   

Doctors have been specializing for years and I think you will see more of this in the NP programs, so look at other specialties that interest you. Apply for an Adult Nurse Practitioner with a specialty in Occupational and Environmental Health or a Psychiatric Nurse Practitioner. Apply for a CNS in Oncology or Cardiovascular care. If you really do not want to have direct patient care you can go into research and get your PhD. Adding a minor to your specialty like forensic science, palliative care or global health can only help.

Again, the biggest thing is to apply. No matter who wins in November there is a growing need for nurses with advanced degrees. I remember in the fall of 2009 thinking I am too old and it will take too long to go back to school. Well, I am done soon and anyone starting next fall will be done before the 2016 person is sworn-in.

If you have never been a nurse and have a degree in another area, there is always the MEPN option if you want to be an NP, CNS or other specialty.

So how do you become a Nurse Practitioner. Apply

*This was all my opinion and if you have any questions ask. I only guarantee that if you do nothing you will not get in.