%20(1).jpg)
My Nursing Mastery
My Nursing Mastery
Friends of Flo - Ethical Nursing and Navigating a Tough System
Lateral violence with nursing slash bullying whatever you want to call it. How does this affect the bottom line.
Narrator:This episode of Friends of Flo is brought to you by NCLEX mastery. If you're a nursing student and you're about to take your NCLEX, you need to go to the app store right now and download NCLEX mastery.
Rebecca:It costs about a hundred thousand dollars to replace a registered nurse, a bedside registered nurse
Andrew:That's a lot of money.
Rebecca:It's a lot of money. A study was done in one of the big Midwestern universities that found that 32 registered nurses were ready to flee in the next two weeks. So hospitals should have their finger on the pulse of this kind of behavior. But the other thing that happens is when you think about being belittled, gossiped about, disrespected, yelled at, have things thrown at you. Not having, not feeling safe to ask questions. Who suffers besides you? The patient. Patient safety bottoms. Medication errors. One of the biggest things that happens as a result of lateral violence in nursing or a lot of it is physician driven. Physicians or nurses is you phone your physician to get clarification of an order and what happens? You get yelled at. Or they belittle you. That has happened to me as a bedside nurse more times than I care to count.
Andrew:I imagine that's happened to...
Rebecca:Everybody
Andrew:The majority of the nurses that are...
Rebecca:And I learned to talk back. I learned to say this is a wrong order, I will not do it. If you want it done you come and do it.
Andrew:That is a skill that is picked up with time. Do you guys agree with that?
Rebecca:No, it's something you should be learning Rachel talked in our earlier cast about this being taught in Nursing school. You have to learn to be assertive. You have to learn to know what to say. So when somebody belittles you and humiliates you have to respond by saying what is at stake here is not me. It's the patient. If you humiliate me I am not going to be asking you questions and a patient is going to suffer. Let's talk about the patient. Let's keep this about the patient.
Rachel:And something I was told when I first started was the appropriate way to quote unquote cuss. So first show concern. Ask for a clear picture to help them help you build a better understanding.
Rebecca:Right
Rachel:And then bring it up as a safety issue
Rebecca:Right
Rachel:And if they're not understanding you...
Tess:So that's an acronym then or mnemonic."C" is for what?
Rachel:Concern
Tess:Concerned. And then"U" is understanding helped me understand your perspective.
Rachel:Right. Or help me understand the order, why did you order it that way. This can be nurse, doctor kind of goes across all multidisciplines
Tess:And then"S" is a safety issue?
Rachel:Yes
Tess:Can you show me how you use that as an example? Can you think of one off the top of your head?
Rachel:I guess, say a patient is acting out violently. Like maybe in the day room they're throwing things I might say say I need an order for haldol or another calming agent for my patient I might say hey you know I have a question about X patient. I'm really concerned about their safety. They're out here throwing things. I would like an order for haldol. Does that make sense to you? If not is there something else you know is there an alternative approach? That's kind of the understanding part. I think you can move those letters around if you need to depending on the severity of the situation and how much you want to be heard.
Tess:Interesting
Rebecca:That's a really good one
Tess:Because I love to cuss. I do. I'm going to remember that when I do. We love to crack a little. I know, it's my military background.
Rebecca:And in a gym
Tess:And in the gym
Rebecca:That's a safe place
Tess:It is a safe place, oh goodness we pump some iron don't we Becky.
Rebecca:Yeah, that's how we came up with this idea that we needed to be...
Tess:We did. We did a lot of...we have a one to one ratio at least sometimes a two to one workout...talking to exercise ratio. So it's usually a one to one, but sometimes we stay later and we have a 2 to 1 talking ratio of exercise...
Andrew:Exercise that jaw
Rebecca:What do you do Rachel? How do you look after yourself?
Rachel:Like take care of myself person personally.
Rebecca:Yeah. What do you do for fun?
Rachel:I like to go hiking. I like to definitely spend time with my family.
Tess:I think you're getting married soon.
Rachel:I am
Rebecca:Are you? Congratulations!
Rachel:Thank you, in September. So that's been keeping me busy and I bought a house a month ago so I'm busy
Rebecca:Oh my gosh, great. You have a lot of new things going on in your life.
Rachel:Yes
Rebecca:New job
Rachel:Yes
Rebecca:New marriage
Andrew:New house. That does sound very stressful though. I mean...
Rachel:No not ever. No I'm kidding.
Tess:Well sort of we can move into this discussion what's going on currently.
Rebecca:There's a lot going on
Tess:We're getting a lot of you know the Comey hearings we're last week. I mean we do like politics and I think we all think that nursing being involved in politics is important. It depends on how much of a junkie you want to be. But if you paid attention to politics it's really distracting right now because of the Comey hearings and what's going on with that investigation. And then of course we had the horrible shooting that happened yesterday in Virginia. But what's going on if you're listening to healthcare or thinking about healthcare is what's going on with the repeal or replacement of the Affordable Care Act
Rebecca:Or Obamacare as some people call it
Tess:Depending on how you want to call it
Rebecca:That is really really concerning me. I'm Canadian. I'm Canadian-American. A Canoodlian.
Tess:Keep your stick on the ice
Rebecca:Keep your stick on the ice. Watch the puck. So I find this whole discourse terribly frightening. We were talking earlier before we went online here about the possibility of Medicaid being stopped in the next...
Andrew:Seven years
Rebecca:Five, seven years and I don't know whether that's rumor or...we don't know anything because the Senate is not holding any hearings and they could pass this, it could go right back to the house. I mean I can feel my blood pressure going up already.
Tess:So there's a lot going on
Rebecca:There's a lot going on
Tess:So you know they put forth the AHCA. I think it's the American Health Care Act, I think is what it stands for. And so the House Republicans put that together and it passed. I believe it passed and then it went over to the Senate and the Senate it's not it's not palatable to everybody and of course they have to get more of a majority in the Senate which is challenging with some of the moderates. So right now it's in what I think is a behind closed door session with about 13 senators
Rebecca:13 white guys
Tess:Maybe a woman in there too
Rebecca:No, I don't think...did they bring in Dianne Feinstein?
Tess:No, I don't know...and I don't know all the ins and outs of it, but I do know that they want to stop the federal funding for Medicaid and that was a lot of what's going on right now I think is the timing. And the people that are listing don't know...the details of it are interesting to me. But what I hear is the concern about funding for Medicaid that we get from the federal government with Medicaid being a state program, but we get federal dollars and ending federal dollars and we can have broader discussions on you know politics and how you feel about funding for health care and all of that sort of thing, but that's a different discussion. But if you feel like it's moving too fast or you're not supportive of it then there's some folks and places to go to talk about, especially states that have senators that are kind of moderate and thinking about that, think Alaska is one and Arizona, but really we should make sure that we have the contact information. And then it gets to the broader issue of being politically involved and then is healthcare right? And last, but not least, which I think is really interesting is all of this stuff is changing. It's not like we're getting more money to take care of people period. The pot is never going to get bigger. We're never going to have more money to take care of patients. And this is where nursing leadership needs to take place. I mean who's going to this is where preventive health and all of those sorts of things. I think in the midst of this kind of sad chaos is opportunity for nursing to say here's what nursing does with the sickest and most vulnerable people and we can see some solutions.
Rebecca:I remember when I get my education at Simmons College in Boston. A shout out to Simmons College. As nurse practitioners we were taught that we were there to care for the most vulnerable and people who were choosing between groceries or a tank of gas or should they go and see us because of a cough that they've had. They can't afford a chest X-ray and they could never afford a C.T. scan or an MRI. So we were taught basic physical exam, but really nurse practitioners and nurses in the hospital, nurses in the community...community health nurses are so important. People that are out there doing home visits who are walking the streets who are going to inner city...rural communities where people are so isolated and have absolutely no ability to get healthcare and that's where. rural health care nurses, community nurses can really step up.
Andrew:And I think that's the scary part if there are programs that are currently on the dock to be cut. From a federal health care standpoint those marginalized populations will suffer. And then in a broader picture as institutions will suffer. Hospitals, not to mention large practices who get their funding from different parts of Medicare or Medicaid, will suffer. To Tess' point of our population of people especially with the aging baby boomer population...that's not going to get any smaller. So you have a constricting...the economics just don't fit this puzzle very well and I'm not saying I have the right answers, but just some talking points. We have dollars that are shrinking to take care of a population of people that is growing and then we have frustrated providers that are oftentimes leaving the profession because of the politics and it's trickling down into not just from a federal level, but into the very local levels.
Tess:When you think about the people that Medicaid take care of their your disabled folks, right? Mentally and physically disabled. I think that's Medicaid was started...before we jump in again I want to, it's actually there's one woman I just looked it up Rebecca. There's one woman on the on the thing. I don't know who it is. I can't tell you who it is. But there's one woman. And nobody's saying that that the Affordable Care Act is perfect here, that's not the issue. It's that it's being rammed through and without open dialogue from all parties who are influenced to change this and hurting the most vulnerable. There's no question. And we don't have that score that comes out from the CBO, the Congressional Budget Office that says how many millions of people are going to lose their insurance...and that the timing is interesting on it too because if you follow politics they want to get this voted out of the Senate before the 4th of July recess so that if it's not out of the Senate by then then the senators will have to go back to their home districts and then they'll hear an earful. So there's some political maneuvering to get it out, but if you're really interested and this is something that calls to you then please go to like moveon.org or indivisible.com. I think it's indivisible.com
Rebecca:Call you senators office
Tess:Let em' know. So like I said you can have your opinions on healthcare and such it should be an open deliberate debate.
Rebecca:My concern is that these incredibly powerful lobby groups like the pharmacy, pharmacology, Big Pharma has such a stake in this and I'm not denying corporate America their share, but they need to be limited in profits and all of that profit needs to be turned into research that is not going into the pockets of shareholders. I know I'm standing like a left leaning liberal which I mostly am not, but you have to look at who is costing them money.
Tess:It's all about following the money isn't it? And that's I think why nurses are, we're very respected profession because that's not seldom been our agenda, you know what I mean? That is not our agenda is to follow the money for care. And I mean we all want to get paid what we're worth and the system and...but I don't know. That's one reason why I think we're a respected profession. So back talking about how all of this stuff affects us at the bedside or taking care of patients and especially in my practice is in a rural setting and then or we see people from all over you, Rachel, at the university that go off to places where you know there very vulnerable patients and you realize that that sometimes only safety net they have is the Medicaid insurance that they have.
Rebecca:I think about the care of the mentally ill in our state that it's been taken away from the government sold it to managed care organizations who have really contracted and diminished the amount of services available and are not paying, their withholding payment to providers. And you think about the number of mentally acutely mentally ill people that end up in the E.R. with nowhere to go. And then the sheriffs are are driving them hours away to the first available bed away from family, away from support, away from their community because that's the only place where they can get care.
Rachel:Right. We see that all the time. We transport patients up to you know five hours away per ambulance per Sheriff per...whatever's available is to take them to these facilities...the hospital just eats up money.
Rebecca:Can you imagine being that person put into an ambulance and not knowing where you're going and you can't follow and you can't think and you're so acutely ill and no one is around that knows you.
Tess:This is what's frustrating nurses. We think that we're powerless in the situation and then getting advanced degrees so this is and we talk about...I don't even want to know if we should segue into people leaving to be direct care providers as nurse practitioners...
Rebecca:I just want to go back one step.
Tess:OK
Rebecca:To ethics and our code of ethics. In the seventh and eighth provisions it calls for us to be politically active. Doesn't matter what your politics are. It's not saying are you voting one way or are you voting another way. It's not even saying are you voting. But we have a moral obligation to be involved in our professional organizations and a moral obligation to be involved in our communities.
Rachel:And I think that role is especially important because we as nurses know that most of our patients that we care for aren't able to do that themselves. And I think that's just even a bigger call to action for nurses.
Rebecca:When I trained as a nurse practitioner in the last century, no laughing you guys. Oh Tessie!
Tess:I was there too Becky
Rebecca:OK. All right. So we were taught that we were there to care for people who had nobody else to provide care for. So we were there to care for the most vulnerable people. And I remember we did case based learning. And I remember the scenario that stuck with me the most was that a woman came in to see you with a cough and she had three or four kids, no money, no money and she had this cough. And the nearest nearest clinic with radiology, with X-ray ability is 55 miles away. What are you gonna do? How are you going to help her set her priorities? She has no food in the house you learn. She's got a cough. She's got three or four very hungry kids at a gas tank that's mostly empty. This is real life
Tess:Well and this is what I say when I when I talk about nursing, too. I say, there's no end to the problems that nurses take care of.
Rebecca:I know, but what I'm also saying is that we were taught to use a stethoscope
Tess:For sure
Rebecca:We didn't rely on an MRI, a CT scan, a chest X-ray. So when I moved here to Iowa and I was a nurse practitioner in a big hospital. I diagnosed somebody using*unintelligible* I discovered a left lower lobe pneumonia. I was so excited. And you know what the response was? Go get a C.T. scan, why are you doing that? And I thought this is why health care costs so damn much money is that nobody's using your brain.
Andrew:It needs to be empirically proven.
Rebecca:So somebody would say, oh well if you don't diagnose it right you're up for legal liability. But you know how much a radiologist gets paid for reading an X-ray that you've already diagnosed? And it's a community acquired pneumonia in a otherwise healthy person, hello!
Andrew:So then let's talk about the ethics of this situation. So if someone comes in my clinic for instance I might be inclined in this situation where she has a cough, she has four children, she can't afford care, why not go to your sample closet?
Rebecca:Exactly
Andrew:And maybe maybe you know if if she's showing signs symptoms of pneumonia you get out your 7 day ZPAC. Give it to her as...
Rebecca:10 day
Andrew:Whatever it may be and then you're your teslon pearls maybe, maybe you have some of those to decrease her symptoms make her feel more comfortable. I would have no qualms about doing that in my current clinical setup. I see a lot of marginalized older folks that live in nursing homes some who are on Medicare or some form of welfare program and they can't afford a lot of their care. Some are DNR some don't want additional medical intervention including going into the hospital or other institution for chest x rays and C.T. scans. Does that mean that we don't treat them? Like, absolutely not. I mean we we still have an obligation to make them feel comfortable and in this kind of situation your situation of having that that patient I can relate and that we can still treat these people and be financially responsible with our approach.
Tess:So them I think it's managing your own self too. Like this is still good care.
Andrew:Yes
Tess:And even though the system says, oh my gosh why didn't she get this. Why didn't you go for the MRI or whatever...or why didn't you provide the most expensive antibiotic when maybe doxycycline will be just perfectly fine and has been for decades. So dealing with this like good enough or...good enough is actually very appropriate given everything you have to take into account.
Andrew:Yeah, exactly.
Rebecca:I think about nurses in the hospital and knowing when it's safe to discharge a patient, knowing where they're going to go when they're discharged. Who's going to be looking after them. And that's all part of really great nursing care is knowing your patient and being able to stand up and say to your physician team to the insurance company that this is the kind of care that's need for this patient. And you're not going to get it where you're going. I think it is responsible care and it goes back to what we were talking about earlier on how much healthcare costs. And I don't think nurses are being used.
Tess:Absolutely. And this is the point too is that in the midst when you were talking about your story, Andy, about that patient to me I was like that is so freaking cool. It's exciting to be faced with a challenge that makes you use your brain. And that says, great we don't have these risks like being on a desert island and you get like a thing of rope and plastic bag you know...
Andrew:And a gum wrapper
Tess:So how can you make a great patient oriented solution that is going to matter to them and that you know is solid and just going to move the problem forward, but you know that's why nursing scope of practice is so broad. You know there's no...you're gonna treat the...and do the right antibiotics, but all of the other things that you take into consideration are so broad
Rebecca:I want to be sure that we are not glamorizing being a nurse practitioner or a certified registered nurse anesthetist, that we are also going to talk about how important bedside nursing is and frontline nursing is and that's where we need a lot of really, really smart people. Those are the nurses that are going to be leading the change and being the change
Tess:And being creative too, being creative about the solutions because this is a great time for nursing leadership, creativity, and smarts. And that's what the health care system needs because currently it is broken and there's...but cracks...that opportunity. All right so we have to end. Keep your eye on the patient.
Rachel:Be the change
Rebecca:Be kind to one another
Andrew:I'll watch you if you watch me.
Narrator:Friends of Flo is brought to you by NCLEX Mastery go to the app store right now, download NCLEX mastery. And before you leave, if you could just share this with your nursing friends, tell them about us. Leave us feedback, go to our facebook page, tell us what you liked, tell us what you didn't love so much, be nice; but thank you so much. We really appreciate you.