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Why We Shouldn’t Be Surprised a Nurse Contracted Ebola in the U.S.

tonydokoupil

Note: I have intentionally not linked to NBC’s post about Nina Pham, RN’s nursing experience. Critical care nurses must meet exacting requirements prior to receiving critical care certification. Critical Care certified nurses have already put in the time. Please reference this FAQ from the American Association of Critical Care Nurses

Anyone making comments about the nurse who contracted Ebola and her competence or her thoroughness needs to read this article. If you are a nurse or physician or other healthcare provider who does not work in a biohazard containment facility, you need to rethink. Remember: people who are experts with this clothing get Ebola. Are we surprised that people who are not experts could contract it? The issue is training and skill level. We should not be surprised that people who have never been around Ebola are not experts at containing or contracting Ebola.

(update added at end of post)

I’ve known for years (and I think a lot of people have) that Ebola would get to the U.S, but I still haven’t been afraid of it because you remain more at risk of being shot by a police officer or security guard even if unarmed in the United State than of catching Ebola. Even as a nurse. You are at higher risk to die of diabetes, the flu, or by a drunk driver than you are from Ebola. You have this risk simply because you live in the United States.

But what I DO know… due to my burn scar, I can’t wear a traditional TB mask. I have to wear a PAPR hood. However, I’ve never worn one. I don’t even know how they work. Still, if I had a TB patient, I’d be expected to learn how to care for the hood as well as the patient. I’ve never worn one. That’s…. not comforting. (In addition, workers at Texas Presbyterian were not given Hazmat suits until a positive Ebola test was received).

I think it’s time hospitals,  nursing, and medical schools started adding biohazard PPE training to their regimens. I think the United States should fund this. I think they can do it by reversing the decision to slash the Hospital Preparedness Program from $515 million to $255 milllion in 2014 and the Public Health Emergency Preparedness Program from $900 million in 2005 to $610 million this year. (Links found from “Ebola Highlights Public Health Crisis“)

The United States has thousands of hospitals, all staffed by medical professionals who have dedicated years of their lives to careful education and preparedness for the care of any individual who may be hurt or ill. Is it too much to ask that the United States not ask for actual years off of our lives?

 

Edit:

After initially posting this, I came across this article from Oregon Live  that states, according to records obtained by the AP, Texas Presbyterian did not place it’s staff into Hazmat suits until Duncan’s Ebola test was positive.

 

So:

 

Patient from Liberia: Check

With explosive diarrhea: Check

Vomiting: Check

High fever: Check

Hazmat suits? Let’s wait for blood results.

 

I really hope that article is wrong, but I don’t think it will be.

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Calling Out Vs. Calling In: How Activist Techniques Can Be Used to Decrease Lateral Violence and Bullying in Nursing

A little while ago, I had the privilege of reading Calling IN: A Less Disposable Way of Holding Each Other Accountable by Ngọc Loan Trần. The essay is well written and thought provoking, and brought a new idea to the way I practice feminism and activism. I keep thinking back to this essay and what it could mean in my personal life. What if we brought Trần’s idea of “Calling In” to nursing? Could we find a method of speaking to each other that comes from a place of concern and love? When speaking from that place of concern, could we use language and tone in such a manner that lateral violence and bullying on our hospital units is decreased? Could we actively support one another to improve our patient care without bringing someone to tears? I think we could.

From the essay:

“Most of us know the drill. Someone says something that supports the oppression of another community, the red flags pop up and someone swoops in to call them out.

But what happens when that someone is a person we know — and love? What happens when we ourselves are that someone?

And what does it mean for our work to rely on how we have been programmed to punish people for their mistakes?

I’ll be the first person and the last person to say that anger is valid. Mistakes are mistakes; they deepen the wounds we carry. I know that for me when these mistakes are committed by people who I am in community with, it hurts even more. But these are people I care deeply about and want to see on the other side of the hurt, pain, and trauma: I am willing to offer compassion and patience as a way to build the road we are taking but have never seen before.” (Trần)

While Trần’s essay deals primarily with actions within the activist community, I see a lot of parallels with nursing. A good example is shift report. Generally, report is a smooth transition, performed by thousands of nurses each day to get one shift in and another shift out. Everyone’s goal is to get through report quickly so the oncoming nurse can get to work and the offgoing nurse can get some sleep. Report isn’t always seamless, and a big part of that comes from nurses. There are nurses who approach report aggressively, and by the time the offgoing nurse has finished, that nurse feels like they have been through a battle. This is lateral violence.

There are nurses who seem to look for mistakes and consider themselves blameless. Now, we are all going to make mistakes, and because we all make mistakes, we are all going to FIND mistakes. Some mistakes are big, and have a lot of people involved. Some mistakes are small, and are the result of action or inaction by one individual. Regardless of the level of mistake, we should never berate one another or treat one another in a hostile fashion. Rather, we should deal with the mistake, and if we are in the presence of someone who has made a mistake, we should not talk to them as if they did not have a nursing education. We should keep in mind that this is our co-worker, someone we trust and have worked with as a team member. We should tailor our language and our tone to maintain professionalism, patient confidence, and the relationship of trust we have built as members of the patient care team.

When another nurse is aggressive during a nurse to nurse interaction, it is lateral violence. When a nurse is aggressive toward a CNA or other member of ancillary staff, it is BULLYING. This happens to CNAs more often than nurses are willing to admit. It can happen as a result of stress. It can happen as a result of miscommunication, but it happens. We need to be aware, as nurses, of the potential we all hold to be bullies on our units, and to watch our tone, watch how we delegate, and to be aware when our CNAs simply cannot handle one additional task, and that we need to do something ourselves. We are ALL working hard. When viewing bullying by a nurse to ancillary staff, it is important to speak up and stop the bullying behavior. Trần’s idea of “calling in” gives us a new technique to use when we see bullying behavior in a co-worker for whom this behavior Is abnormal. What is causing the behavior today? What can we do to stop the behavior and save the relationship between the nurse and the ancillary staff?

So what is the difference between calling out and calling in?

Trần works to define (and states this is a work in progress):

1) “The first part of calling in is allowing mistakes to happen.”

(Now, in nursing, if we see a medical error about to happen, if we see a safety issue, we should always speak up. I am not advocating that we allow preventable medical or safety errors to happen. In nursing, we should be aware that mistakes will happen and we will have to deal with them, but it is how we deal with mistakes that either brings us closer together or pulls us apart)

2) Think about “what makes my relationship with this person important?”

            Are they a long time co-worker? Are they a new graduate? Are we friends? Do we know they’ve been having a rough time lately? What do we know about our co-worker that makes them valuable?

How do we start these conversations? Again, Trần has put a great deal of thought into this, and nurses do not need to stretch far to see how Trần’s model could be used to decrease lateral violence and bullying on our units:

I start “call in” conversations by identifying the behavior and defining why I am choosing to engage with them. I prioritize my values and invite them to think about theirs and where we share them. And then we talk about it. We talk about it together, like people who genuinely care about each other.”

Additionally:

“I picture “calling in” as a practice of pulling folks back in who have strayed from us… Calling in as a practice of loving each other enough to allow each other to make mistakes; a practice of loving ourselves enough to know that what we’re trying to do here is a radical unlearning of everything we have been configured to believe is normal.”( Trần)

Trần discusses how we have “configured to believe it’s normal to punish each other and ourselves without a way to reconcile hurt.” This is where nursing needs to look up and examine itself closely as a profession. Too often do we see a mistake and rather than deal with it quietly, we mention it to our co-workers. We say “someone was having a bad day” or make comments that lead others to believe our fellow nurses are now not as trustworthy as they might be. Comments like these undermine nursing as a profession. They undermine the teamwork on our units, and they break down the relationships among nurses.

It should not be “normal to punish each other.” Instead, when a mistake is noted, deal with it. If the mistake needs to be reported, do so quietly and efficiently without involving others, if possible. If you need to involve someone, involve someone who will also be discreet. Offer your fellow nurse a shoulder, support them if they need to take a moment for self-care. Be aware of the signs of compassion fatigue or burnout.

By incorporating the idea of “calling in” rather than calling out, we can decrease the incidence of lateral violence and bullying on our units. We can make our workplace more professional, and less stressful. We can encourage each other to participate in self-care to stay mentally and physically healthy. We can be better nurses, and we can elevate the nursing profession.

I would like to address the issue of “calling in vs. calling out” as it relates to ancillary staff. If a nurse finds an error made by a CNA, “calling in” can still be very useful, but nurses need to remember the potential for bullying in these situations. There are different power dynamics involved with nurse-CNA interactions than with nurse-nurse interactions, and the potential for harm here must be acknowledged. Remember how humiliating it can be to be “called out” at the nurse’s station, in a patient’s room, and afford all of your co-workers the same respect, and do not use these power dynamics to better yourself, but to better all staff.

How a Bad Nurse Inspired Me

When I was 23, my grandmother was dying of lung cancer.

My Grandma H was one of the strongest women I ever knew. She ran her own business, was an active church member and helped found my home church in Missouri.

But she smoked. She and my grandfather smoked for decades. Everyone did.

Then my grandfather got cancer and she quit cold turkey. She still got cancer.

This woman also got Type 2 diabetes and changed her diet overnight.

My grandmother wasn’t perfect. She had a temper, she was set in her ways, and she was, at least, at one point, a racist. She kept her racism well hidden, and I only ever heard a racist comment from her shortly before her death when she was having a lot of problems. I don’t want to think of my grandmother as a racist, but I know it was there at some point. Still, she welcomed her black customers and was well thought of by the black community in my hometown, as I learned after her death. I’ll never know her true stance because my grandmother never taught me to be a racist. She kept her opinions to herself.

I was visiting my grandmother and she was in the hospital. She was dying of lung cancer and COPD. I was staying at my Grandma C’s house. It was quickly obvious that my grandma was dying, and I needed to be there as much as I could. My job at Charles Schwab refused to let me take time off, but I was fortunate to have a standing job offer from a previous employer. So I quit. I’ll never invest with Schwab. They claimed to be a family friendly company and refused me time off with the woman who practically raised me.

At this time I was also trying to decide which college to attend, and what to major in. I wanted a guaranteed job, I wanted to make a difference, and I wanted a living wage. I loved science, and was toying with the idea of being a nurse. I was currently working in customer service and tech support and hated it.

I was at my Grandma C’s house, in my pajamas, and got a call from the hospital. My grandmother was actively dying. I raced to the hospital to find my grandmother pale, her fingers blue, and barely coherent. No one was in the room with her. She begged me for help. I quickly tried to call for help and was told by the nurse “She’s dying.” My grandmother was in agony. I’d only seen her close to that once before, when she’d forgotten to turn her oxygen on. She was not being medicated for her shortness of breath or anxiety. She was literally sitting in a chair, gasping to stay alive. Yes, she was a DNR. This was my first lesson that some medical professionals consider that to be an order not to treat the patient.

In tech support, one of the first questions we always asked was “is it plugged in?” My grandmother’s oxygen was not plugged into the wall.

I called the nurse’s station again, desperate. No one came. I walked out to the nurse’s station to find the nurses sitting down and talking. I quickly asked for help to plug my grandmother’s oxygen back in.

A nurse marched down the hall with me, plugged the oxygen in the wall and said:

“You could have done this YOURSELF.”

Within minutes, my grandmother had her color back. She had her breath back, and she was thinking more clearly, although she never regained her sharpness of wit or memory after that moment.

As I sat there, holding her hand, feeling her desperately rubbing her thumb over mine, which she did to comfort me, but also to comfort her, I thought of that nurse, and I thought: “If that moron can do it, I can do it.”

I filed a complaint with the hospital and received an apology. I was reminded very shortly that my grandmother was dying. I didn’t really think of suing the hospital because I knew she was dying and I had already had a horrible experience with a false medical lawsuit filed by my mother. Litigation was the last thing on my mind. If that had happened today, I would raised hell. But back then, I was 23. I had no idea of a patient’s rights. I was alone in the hospital.

Nursing school was brutal. I worked full time through the entire thing, sometimes just sleeping 2-3 hours a day between classes and on breaks at work. I haven’t gotten to work in pediatrics. I work in surgery.

Every time I go into a patient’s room, from my first day as a tech and until the day I leave nursing, I check the patient’s color, respiration, effort, and whether or not their oxygen is plugged in. If they are on a tank, I bend over and check, every time. I’ve found other nurse’s patients with their oxygen off, cyanotic (blue), and averted a code. I monitor my medicated patients closely.

I’m not a perfect nurse. I screw up. I lack patience at times. I have compassion fatigue and I’m burned out from working a hard, physical job while coping with chronic illness and pain.

But when I had a dying patient, the other nurses covered my patients completely so I could stay with her. I held her hand and turned her toward the mountains, so that if she could see, the last thing she would see was beauty. When I talked to her son who was rushing to her side, I was able to truthfully tell him his mother did not die alone.

I have never told a family member to do anything by themselves. I will never treat a family member like they should have medical training. If my patient is in distress, I am in the room.

That nurse is probably still working. I never got her name. Her inaction made me a better nurse. I will never, ever, let myself become so fatigued, so burned out that I knowingly let a patient suffer while I sit at the station, talking. It’s just not the kind of nurse I’m ever going to be.

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