Tag: Health

Unique Closure

Sunset

This week I reviewed Washington State Nursing Care Quality Assurance Commission records for Kimberly Hiatt—the 1,500 pages allowed under public disclosure. I had requested these records in order to look at the primary sources unfiltered by journalists or people close to the case. I also requested them as data for a journal article I am preparing on health workforce regulatory systems. Kim’s story continues to disturb me. I won’t repeat her story here, since it has been told in many other places (and most completely/accurately in my opinion by JoNel Aleccia/MSNBC). Instead, I will share my main impressions, thoughts, and unanswered questions.

My overarching impression is that the entire cascade of events contributing to Kim’s suicide could have been prevented. A secondary impression is just how complex our health care system is—how prone to errors of all sorts, not just medical errors, but errors of judgment by people in various levels of the healthcare hierarchy. It is not any one person’s—or one institution’s—fault. However, all along the way, individuals with power could have significantly altered the course for Kim. And nurses were turning on other nurses within this cascade of events. Not only nurse administrators, but also nurse colleagues of Kim’s. (I should note that there were also nurse colleagues who were quite supportive of Kim–and these show up in the record as well.)

But some of Kim’s colleagues were making unsubstantiated accusations, including a sophomoric and trumped-up sexual harassment charge by seemingly homophobic co-workers (and from the record, not handled well by hospital HR). This sexual harassment charge by a female nurse against Kim involved the fact that Kim was openly gay. That this could happen in a modern-day US hospital is dismaying. That this could happen in a US hospital in a city with the highest per capita population of lesbian-identified women is appalling. Then there was the more recent charge (by an ICU nurse) of Kim abandoning a patient. An investigation of this charge found that physicians had called Kim into help with a difficult parent conference, and Kim had arranged coverage for her patient.

Nurses could have prevented the negative outcome: shame on us.

Kim had worked at Seattle Children’s Hospital for 24 years on several different units. This was her first major medical error. The Cardiac Intensive Care Unit where Kim worked had just offered her a permanent position. Her last performance review dated 8-24-10 signed by the Director of ICU rated Kim’s performance as a 4/5 “Leading Performer.” Annual job performance reviews going back to 1994 are similarly high, with a peer writing, “Without a doubt, Kim is one of the most skilled nurses on our ICU.” Then, immediately after the medication error, in a report to the Nursing Commission, this same Director of the ICU (and a nurse herself) expressed concerns about Kim’s nursing practice—that she “failed to partner with leadership and work to correct the situation that could have caused her to make the failure.” Kim had immediately reported her medication error—had helped the medical staff remedy the situation—had disclosed her error to the baby’s parents with the support of the lead physician—then had been escorted off hospital property/put on administrative leave, and soon after was fired. Where exactly was Kim’s failure to partner with hospital leadership?

The initial report of an adverse event sent from Children’s hospital to the Nursing Commission stated: “an overdose of medication to an infant, who died as a result” even though it was not clear (and remains unclear according to the medical examiner’s final report) that the overdose contributed to the baby’s death. It was also reported this way in a memo by the CEO of Children’s hospital—that was then picked up by KOMO News and the Seattle Times. Guilty until proven innocent. The Nursing Commission member’s e-mails/memos acknowledge this “heavy media attention” as pressuring them to make Kim’s ‘case’ high priority. How might this have prejudiced the Nursing Commission’s decision-making process for Kim? The Nursing Commission member in charge of Kim’s investigation is herself a Chief Nursing Officer of a hospital. How might that lens have affected the Nursing Commission’s decision-making process for Kim?

The Nursing Commission refused Kim’s lawyer’s repeated requests for copies of their complete investigative materials—including the final medical examiner’s report—so that he could adequately advise Kim on her options before she was required to sign the final Stipulation of Informal Disposition (the final disciplinary action/sanctions). Why was his request denied?

The Stipulation sanctions included a $3,000 fine, 48-month probationary period where Kim needed supervision for giving medications, Commission approval of any future jobs, and reporting of her discipline to the National Practitioner Databank—as well as made public on the Department of Health website. The Department of Health staff attorney assigned to this case wrote in an internal e-mail “Talking Points” prior to the final settlement, “Tell (Kim’s lawyer) his client may take it or leave it…” Kim signed this Stipulation. A week later she killed herself. Upon being notified of her death, the Staff Attorney for the Nursing Commission advised closing Kim’s case as “a unique closure.” As of today, Kimberly Hiatt shows up in the Washington State Provider Credential Search Database as having an expired nursing license and having had no disciplinary actions.

What does all of this say about the deficits in our health care system? What can nurses—and others—do to prevent this sort of treatment of a nurse? Can anything be done to reform the health professions regulatory system? Can anything be done to hold hospitals accountable for their treatment of nurses?

I realize that it is easy for me to say that nurses need to speak up more about injustices to other nurses, to stop petty in-fighting and not so petty back-stabbing. I am–as spokespersons for Children’s hospital refer to us–an “armchair safety expert who doesn’t know the details of Hiatt’s case.” Except I do know 1,500 pages of details of Hiatt’s case. It now makes less sense to me than it did before. There is no suitable closure–not even a unique closure–for Kim Hiatt’s case.

Limits to the Active Health Care Consumer

Question Everything
Image by dullhunk via Flickr

As health care consumers, we are being asked to become more active participants in our health care. We are admonished to exercise more, not smoke, wear seatbelts, use sunscreen—all of those individual risk and protective factors—as a way of reducing health care costs. We are asked to be more involved in patient safety—to ask our health care providers questions such as “How many times have you done this procedure?” And “Why do I need this treatment” (see AHRQ’s: Questions Are The Answer website.) And to take in a list of questions to ask your provider. AHRQ doesn’t tell you that all of these questions are a sure way to obtain the instant label of Problem Patient

We are asked to become more involved in health care quality, to report errors/concerns about providers, to shop for the highest quality hospital when we have the lead-time to do so. AHRQ tells us, “Do your homework before you chose a hospital.” Online tools for doing this homework include Medicare’s Hospital Compare and the Joint Commission’s Quality Check.

But how are consumers supposed to know if their doctor, nurse practitioner, dentist, or other health care providers are competent? This, of course, assumes that patients still have a choice of providers—a dwindling luxury with managed care and the fact that the really good providers aren’t taking new patients. Most people go by old-fashioned word-of-mouth, or the media equivalents: Doctors Score Card (really just a Yelp consumer rating of doctors) and HealthGrades. (supposedly more objective, risk-adjusted health outcomes data). Patients are generally good at assessing ingredients of quality of care by providers, such as interpersonal skills and hand washing—but not so good at assessing technical competence of providers.

Instead, consumers rely on others within the health care system to ensure ongoing competence of health care providers: peer reviews, professional organizations, and health professions regulatory systems. None of these are exactly transparent or accountable to the general public. Some states have started to provide accessible online searchable databases of doctors/other providers and their practice histories. Most of these are quite rudimentary and not very helpful. For instance, in Washington State, the site only provides the health care provider’s credential type and status, and whether or not they have had any disciplinary actions: yes/no. California has similarly limited consumer information on individual providers—however, their site does provide consumer information on collagen injections. Really. In contrast, Massachusetts on MyHealthCareOptions allows consumers access to information on individual provider’s malpractice claims, hospital and state licensing disciplinary actions, and criminal convictions. Plus it’s a very cool and user-friendly interface.

Then there is the federal/DHHS/HRSA National Practitioner Data Bank—established by Congress in 1986—which has as its mission “to protect the public by restricting the ability of unethical or incompetent practitioners to move from state to state without disclosure or discovery.” The Data Bank collects individual practitioner data on malpractice claims, and disciplinary actions from state licensing agencies, hospitals, health plans, the DEA, and professional organizations—and makes these data available to hospitals, state licensing agencies, and other health care entities—but not to consumers. And now not even to researchers or journalists.

Until this month, researchers and journalists had access to a public use file from the Data Bank, not to individual practitioner data. But this public use file was recently removed due to a complaint by a neurosurgeon in Kansas who was ‘outed’ by a journalist for having a significant malpractice history/never disciplined by the state. (see NYT article “Withdrawal of Database on Doctors Is Protested” Duff Wilson, 15 Sept 2011). The journalist got this information by being a good investigative journalist and not directly from the Data Bank. Journalism organizations, as well as consumer protection groups, have protested the removal of the Data Bank public use file. They point out that resources such as the Data Bank have informed investigative journalism reports on the serious shortcomings of our health regulatory system. These reports have had significant impact on promoting improvements in the system—including attempts to provide relevant practitioner practice information to consumers.

Becoming a Nurse

Nurse uniform in the 1900's.
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When did I become a nurse? Was it when I carried a burning candle, wore a silly white hat and got pinned in a church in Richmond, Virginia? In my memory I could swear that my pinning ceremony church was St John’s where Patrick Henry gave his “Give me liberty or give me death!” speech but that can’t be right. I do accurately remember that it was the first and last time I ever wore a nurse’s cap. My childhood Winnie-the-Pooh has worn it ever since and I am sure there is deep symbolism there…

Was it when I passed my NCLEX exam? Or perhaps my first day on the job as a public health nurse, decked out in navy blue? Or was it a year later on my first day on the job as a nurse practitioner at a health clinic for the homeless—when I found myself in charge of the clinic as the only health care provider and willing down my breakfast and my fear? Or am I still becoming a nurse or do I even want to be a nurse?

“Becoming” is a coming into existence. It implies a right of passage, assuming a new identity, a transition from one state to another—such as “becoming an adult” or “becoming a butterfly.” A quick Google search of “becoming a nurse” reveals many website links to things like “10 Steps to Becoming a Nurse” (NursingLink): learn about the nursing profession, find your path to RN title, chose nursing school, get into nursing school, decide on specialty, pass NCLEX, consider possibilities for first job, get hired, prepare for first year as nurse—presto! You have become a nurse! Good luck with that, most nurses burn out in their first year as a nurse…  “Becoming a doctor” has similar elements—MCATs, med school, residency, etc—but also includes things like “excel” and “commit.” There are at least twenty books in print with “becoming a doctor” in the title and only five  with “becoming a nurse” in the title.

Soon there will be an additional book on becoming a nurse and you nurses or ‘becoming nurses’ could be part of that book. “Becoming a Nurse: Real Stories of Nurses, Their Lives and Their Patients” is a book project by Lee Gutkind, editor of the journal Creative Nonfiction. They have a call for submissions (deadline November 30, 2011) for 2,500-5,000 word personal essays, “…stories (by nurses) that recall and recreate the most salient moments of their careers.” (Excerpted from their website call for submissions).  Jenelle Pifer, Assistant Editor of Creative Nonfiction has assured me that they want to include “a variety of perspectives on a number of different subsets in the field”—that includes nurse practitioners and all other flavors of nurses.

Creative Nonfiction, with Lee Gutkind as editor has already published a book Becoming a Doctor (Norton, 2010), with essays by well-known physician-writers such as Danielle Ofri, Sayantani DasGupta, Perri Klass and Robert Coles—as well as many relative newcomers to the physician-writer (published) role—and one who I think is a stretch to the doctor title (at least in how it was conceptualized for the book project)—Lauren Slater (Welcome to my Country and Liar), who is a now non-practicing psychologist. But it is an excellent book and I plan to use some of the essays as readings for my health policy classes this year.

The Shape of the Eye

Subtitled: Down Syndrome, Family, and the Stories We Inherit, by George Estreich (Southern Methodist University Press, 2011) is a memoir of one father’s struggle to care for, understand, and love his daughter Laura who is born with Down Syndrome. But it is so much more than that. Abraham Verghese states that Estreich’s book “…will become a part of the canon of narratives that are studied and taught in medical humanities courses.” An audacious statement—and the notion of a “canon of narratives’ somehow makes me cringe with its connotation of dogma—but The Shape of the Eye does stand out in the growing crowd of medical memoirs.

When I received a copy of The Shape of the Eye a week ago, I was finishing reading The World I Live In by Helen Keller, and so was already deep into the world of stigma, disability, and language. I live on a steady diet of books and seldom ever regress to my adolescent tendency to devour books when they are delicious. But I read The Shape of the Eye in one long luxurious sitting. It is not like when I stayed up all night reading The Lord of the Flies when I was twelve—under the bed covers with a flashlight. I somehow dozed through the part where Piggy gets hurled to his death. I thought my classmates were making it up during class discussion. Instead, I read The Shape of the Eye during the day, fully awake and caffeinated, and I somehow simultaneously devoured and savored the book. It is impossible to simply devour poetry, and this book is written through a poet’s eye. Estreich’s first book is Textbook Illustrations of the Human Body (Cloudbank Books, 2004), a powerful collection of poetry.

What I like most about The Shape of the Eye is that Estriech manages to weave the main narrative of Laura’s birth, heart surgery and other struggles to live, with his own identities—Japanese mother, Jewish father, stay-at-home father, husband, writer/poet, builder of furniture and other home improvement projects. But all of these intertwined stories are teased apart in places—like the brainy bespectacled Piggy—revealing the science and history behind Down Syndrome. Estreich is also a new and improved version of the scientist, bringing both wry humor and a poet’s exquisite sensitivity to the meaning and metaphor within ‘hard facts.’. A lasting image I have from this book is his description of a pediatric heart surgery parent education pamphlet complete with a diapered anatomically drawn heart. I’ve seen those pamphlets and I’ve used some with patients even though I knew they were ludicrous. The things we do in the service of health care… As I read, I kept thinking of the work of the Australian medical sociologist Deborah Lupton (Medicine as Culture) and her discourse analysis of health education messages. In The Shape of the Eye Estriech essentially ‘does’ discourse analysis—Mongoloid Idiocy, the Simian Crease, Mental Retardation, etc—but in a nonacademic and much more accessible way.

As an academic, I can see Verghese’s point about how The Shape of the Eye is destined to be studied in medical humanities courses. And in disability studies. And in psych/mental health. And in special education.  And in all our other strange academic divisions. But mostly I see The Shape of the Eye being savored—like Estreich does for Laura as a person—just for itself.

Postscript: I had the pleasure today of attending George Estreich’s reading of The Shape of the Eye at Elliott Bay Book Company here in Seattle. As you can imagine from reading any of Estreich’s writing, in person he is witty, wry and humble, and just a pleasure to be around—one of those people who gives energy and doesn’t suck it out from the world around him. As was fitting for today, the tenth anniversary of 9/11, he read one of his poems echoing images of post-9/11 Manhattan. But one of my favorite of his poems in Textbook Illustrations of the Human Body is“Codes.” Referring to an interaction with his mother (also a writer), he writes:

“But a life of writing/is not necessarily happy.

Be careful, she says. Chores can interfere with your work.

Our truest signatures/ are endless, and in code.” (p.13)

Going to jail

Prison ?

Or prison, or juvenile detention, or the catchall, misleading term “correctional facility.” These—along with capital punishment— have been on my mind lately for a variety of reasons.

I recently was offered a job in the health care unit of a nearby county jail. Several years ago I was offered a job in the health care unit of the King County Jail in downtown Seattle. I seriously considered both jobs and went through interviews with the supervisors at both locations. I spent time in the King County Jail and shadowed some of the nurses who work there. For both jobs I was impressed by the level of compassion combined with level-headedness and toughness of the health care staff members. I tried hard to imagine myself working in this sort of environment. In the end, I turned both jobs down. At the King County Jail, as I was interviewing, a prisoner hurled himself down the center doughnut hole opening of the building, falling five floors before he landed on his head on the health care unit beside the supervisor’s office door. I decided that it was a level of trauma that I didn’t want in my life. With the latest jail health job offer, I turned it down because I realized I couldn’t reconcile myself with the complicated ethics of such health care.

In jail and in prison health care is openly acknowledged as band-aid care only—minimal and low-cost treatment for immediate health problems to keep the prisoners alive until they are either killed on death row or have served their sentences. There is no preventative care. A common rhetorical question by prison health care workers is, “Would you rather we spend money and time on health care treatment of offenders or of their victims?” That sounds good in theory, but really, how much money actually goes to help victims of violent crimes? Underneath, it is a political statement by politicians wanting to look tough on crime. Prison is viewed solely as punishment, not as rehabilitation. If as a society we were serious about rehabilitation, investment in preventative health care for prisoners would make sense. But this would only make sense ethically if we had access to basic health care as a basic human right for all people in the US. And since African-Americas, American Indians, poor people, and persons with mental illness are overrepresented in out prison population, what exactly would we be rehabilitating them from?

Instead of working in jail health care, I have decided to work in juvenile detention. This is a group of young people I am already familiar with, since many homeless and street-involved young people revolve through “juvi” as they refer to it. I won’t be working in health care per se, but rather in a health-related activity. This is a volunteer position through Pongo Teen Writing Project. Pongo is a volunteer nonprofit program founded by Richard Gold in 1992. Richard is a poet and former insider in the book publishing world. Pongo’s mission is to help teens who are homeless, in jail, in long-term psychiatric facilities, or otherwise facing challenging lives—to write and express themselves through poetry. I’ve known about Pongo ever since moving to Seattle in 1994. Many of the homeless teens I saw in clinic would bring in journals full of poems they had started writing, sometimes first with the prompting of Pongo staff members in juvi or in homeless youth drop-in centers around town. The teens often wanted to share a particular poem with me, and it became part of the health care encounter. Sometimes they were willing to ask for help with chemical dependency or mental health issues for the first time. As Richard Gold says in a video posted on Pongo’s website, “Poetry fulfills a very practical, intellectual function in healing.”

For me, this is a way I can ‘do’ jail health care. At least I think so. I believe that there are sufficient support resources within juvi—counselors, therapists, teachers, doctors and nurses—the teens can access to help them deal with difficult memories or emotions excavated through the poetry. I also trust in the general truthfulness of the “self-dosing” theory in PTSD: people will only write about/draw about pieces of trauma they are prepared to deal with at the time. I believe that the Pongo Teen Writing Project goes beyond helping individual teens give voice to their lives, but also shares those in an appropriate way (e.g.: with the teen’s permission and using pseudonyms) to help create positive change in the complex web of social supports that have failed these young people.

Cultivating Empathy

Three Way Mirror
Image via Wikipedia

I’m continuing on my line of thought from my last post “On Reflection,” and have been considering how reflective practice and its counterpart of empathy can be taught in nursing school. How can we do a better job of helping students grow in emotional and moral maturity? How can we as health care providers and teachers do a better job of growing in our emotional and moral maturity?

Maura Spiegel who teaches in the Columbia University Narrative Medicine program gave a talk “Reconceptionalizing Empathy” last fall at the Narrative Medicine workshop I attended. She maintains that empathy cannot be taught, it can only be cultivated, and that a common mistake for health care providers in thinking about empathy is the idea that “I can know you—or that empathy can be a conduit into a patient’s inner life.”  The psychoanalyst Donnel Stern maintains that empathy is an interpretation like any other observation, and that empathy is often implicit knowing or “pre-reflective unconscious, an unthought known:” a dimension of experience which is in some sense known, but not yet available to reflective thought or verbalization.”

Metaphor, poetry and art speak directly to our implicit knowing—they are, in Maura’s words, “mediated sources of understanding.” In health care, this is where narrative medicine and the medical humanities step in. Attentively watching movies, reading novels or poetry—or writing and reading our own stories—can tap into the sources of empathy. Language can become an ally again, and the experience of empathy can be made available for reflection. Making more room in nursing curricula for narrative medicine/nursing would be one way to help cultivate empathy in students—and perhaps even in faculty members.

Being able to access empathy and then to reflect on the experience are important skills for nurses. Certain patients or health care situations will affect us more than others. It is easier to have empathy for patients we assess as being “like us” in whatever aspects. Patients, groups or populations viewed as “the other,” are more difficult to have empathy for.

I recently read a collection of essays called The Other by Ryszard Kapuscinski (Verso, 2008). Over his long career as a journalist, he traveled throughout the developing world, reporting on major wars and revolutions. Kapuscinski was influenced in his thought by the philosopher Levinas, who is known for the phrase, “the self is only possible through the recognition of the Other.” Kapuscinski extends that thought by writing, “…the Other is a looking glass in which I see myself, and in which I am observed—it is a mirror that unmasks and exposes me, something we would prefer to avoid.”

Whenever we talk about “The Other” or “Othering” in nursing education, it is almost always in the context of working with patients and groups from “other cultures” or who have stigmatizing conditions such as schizophrenia. We don’t do a very good job at helping students to use their own inevitable discomfort in looking in that mirror to see what is reflected back, to see what is exposed. Sometimes these sorts of issues get handled by students in reflective journals in their clinical rotations, and sometimes it gets discussed in small group seminars—but those times are very few and almost seem to happen by accident. They aren’t explicitly cultivated. One of the problems that I see is that nursing faculty aren’t very comfortable in looking in the mirror themselves, so they aren’t able to model that for students. Encounter Groups for nursing faculty sound like a horror movie in the making, and continuing education conferences on how to cultivate empathy are close behind in the shudder index. One promising change may be that the next generation of nurse educators will be—well—younger, and perhaps more widely educated, more well-traveled, and further along on the emotional and moral maturity scale. That’s my hope.

On Reflection

Noonday Taking A Horse To Water
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In August people check out. While sitting in various meetings this past week, I noticed that even the people who show up in August are mentally checked-out. This was an even more pronounced pattern when I lived on the east coast—for us lefties, every month is a laid-back sort of month. Luckily for me my (noisy) neighbors have checked-out for the week, all packed away on a camping trip. I can hear my bamboo growing. I can hear myself think.

I’m metacogitating: thinking about thinking. If it is anything like thinking about walking up stairs while walking up stairs (and tripping as a result), this could be dangerous. That leads me to reflection and what it means to be a reflective practitioner (of any sort), and why reflective practitioners are important to have in health care.

Two things led me to this topic this week. First, I am on an interprofessional health sciences service-learning group where we discussed ways to encourage meaningful student reflection. Donald Schon’s The Reflective Practitioner was invoked, along with reflective journaling, Rita Charon’s parallel chart, and various narrative medicine sorts of activities. Second, I had a psych nurse ask me why we don’t have nursing students do IPRs anymore. I had to reach back into the scary dark recesses of my brain to even know what he was talking about. Interpersonal Process Recordings—a long and tedious process of reconstructing a nurse-patient interaction, complete with dialogue and non-verbal cues—and then written self-reflection on what went well/didn’t, why, and what could be done better next time. I remember writing IPRs for my psych BSN course. Typically, five minutes of conversation resulted in at least seven pages of writing and reflection and hours of work. Not surprisingly, IPRs originated in psychology and social work counseling programs and were then adopted by nursing. IPRs are intended to be used within counseling supervision—trainees meeting with seasoned clinicians to develop self-assessment and communication skills. IPRs in nursing education have been more in line with creative writing—confabulation—made up dialogue—and aren’t typically discussed with, but are merely written up and handed to the instructor. I don’t remember confabulating my IPRs, but I didn’t discuss them with my instructor—thankfully, as my psych clinical instructor wasn’t exactly a model of good communication (or of good mental health for that matter). I am intrigued by research findings I ran across indicating that the more nursing education students have, the worse their communication/interpersonal skills become. (Harrison, et al. “Assessing Nurses’ Communication” Western Journal of Nursing, 1989). I’m not sure if this study has been replicated on a larger scale and using longitudinal data, but it would explain so much in my life….

Proponents of reflective thinking go way past Schon, to Dewey and Lewin, and back to Socrates. Reflection is a key component of critical thinking—critical thinking being outcome-oriented analysis and an ability to examine a situation from multiple perspectives. Critical thinking and reflective thinking are essential skills for nurses. Health care workers have to make numerous complex decisions affecting patient care. Generally these decisions have to be made quickly, with incomplete and imperfect information. Thinking on your feet or reflection-in-action is a necessary clinical skill—and not lapsing into short cuts or inattention, because that’s where medical errors often occur. Reflective practice contributes to self-assessment and life-long learning—essential for continuing competence of health care workers.

But how do you really teach critical thinking and reflective thinking? By looking through many nursing school syllabi and reading the course objectives, you’d think that critical thinking skills were well covered. However, when you look at what is actually done in those classes and how students are evaluated, it is almost exclusively targeted at ‘lower-order thinking’ in Bloom’s revised taxonomy of thinking: remembering. In clinical nursing courses, the learning goes higher from understanding to applying—and sometimes eking into analyzing. This leaves the ‘higher order’ levels of thinking of evaluating and creating untouched. These are the levels of learning where reflection really kicks in. In my experience teaching nursing at the BSN level, there simply is not enough time or space for teaching to higher order thinking. Basic skills (“Bedpans 101”) of med-surg types of things—the remembering and the applying take precedence. Then there is the issue of raw material to work with, the leading a horse to water sort of conundrum. You can’t encourage the development of higher order thinking in nursing students if they don’t want to drink from that trough.

Aging (and walking) In Place

It has been a year since my father first started showing symptoms of congestive heart failure. His symptoms started last August when he was visiting me from his home in Richmond, Virginia. His symptoms worsened as he did his daily walk, and necessitated a visit to the local emergency room. Last September his cardiologist gave him 3-6 months to live. My first blog post “A Practical Man and Modern Medicine” was about the end of life decisions my father and I were facing—and my frustrations over the fragmentation of the health care system as we wended our way through the labyrinth. The term “rough crossings” for these health care transitions is an apt one. It was difficult for me and I am a health care insider. He was briefly hospitalized in September at the same university hospital where I ‘trained’ as a nurse and nurse practitioner. I coordinated his home nursing care and then (briefly) hospice care—and convinced my father to give up driving. I thanked bad boy Clinton and my university for FMLA (Family Medical Leave Act) so that I could be with my father during what we were told were his final months of life.

A year later, my father is back here in Seattle for a visit. He ‘graduated’ from hospice and home heath after only a few weeks—he was too healthy and independent. So much for medical predictions of mortality. He has come out to Seattle every year for the past fifteen years. He leaves a clunky pair of walking shoes here so he doesn’t have to pack them. A few weeks ago, while he was still in Virginia, he developed pneumonia. He refused to be put in the hospital for it, so my brother nursed him back to health—and then put him on a direct flight from DC to Seattle. Every day since he arrived (rain or shine—it’s Seattle, so it is mostly rain), my father straps on his walking shoes, grabs the lightweight REI collapsible stool I gave him, and heads out for a 30-minute walk. When he gets short of breath, he sits down on his stool for a while and checks out the neighborhood gardens. Back in Richmond, he continues to live at home, relying on neighbors, church friends, my brother and sister-in-law to help out with things like getting groceries and driving him to the bank. He continues to have a huge garden in his backyard which he tends every day. He rides his stationary bicycle nine miles a day and walks outside when it’s not too hot. A retired minister, he visits “really old” people in nursing homes and vows never to live in one: “They just sit there all day and look really bored.” He has a point, and one that is supported by research: aging in place can be cheaper and have better outcomes than the alternatives of nursing homes.

Most people prefer to stay in their own homes or apartments for as long as possible. There is a bourgeoning business related to smart home design and various technologies to support people aging in place. Besides the home monitor, which measures my father’s blood pressure, oxygen saturation and heart rate daily—and which he loves—there are now smart toilets (which measure urine sugar levels) and smart rugs (assume they are wall-to-wall—detect changes in an older person’s gait for fall prevention). But then there is the issue of informal care (unpaid care) by relatives and friends, because that is what allows aging in place to not be dying alone in place.

Current estimates of the economic value of informal care in the US puts it at $306 billion a year, compared with nursing home care spending ($115 billion/year) and formal home health spending ($43 billion/year). Source: RWJ and Peter Arno, “Economic Value of Family Caregiving, 2006.  Upwards of 70% of the informal care workers are female, although the proportion of male caregivers is steadily increasing. Anecdotally, I think that FMLA is partly responsible for this evening out of the gender disparity in caregiving—an explicit purpose of the act. Also, just as in my parents’ case, older married men are becoming the informal caregivers for their wives, as men begin to outlive women. There is growing recognition of the rewards—but also of the burdens—of informal caregiving. Most informal caregivers are spouses or adult children of aging parents. They rarely have any training or experience in caregiving of the sort needed for aging in place, and it is difficult to find needed support for the work they do. Informal caregivers have the stress of lost wages/lost retirement savings, the stress and isolation and physical demands of in-home care, and they often neglect their own health.

Nurses have long been the backbone of home care services. Home nursing services have increased in the US with the growing geriatric population, as well as with the reduction in hospital stays for all patients. Nurses, along with medical social workers have become geriatric case managers, an unlicensed and unregulated ‘profession’ providing care coordination and links to needed community-based services for geriatric patients and their families. There is a National Association of Professional Geriatric Case Managers with a website and searchable database. I checked today and there a four Geriatric Case Managers in Richmond, two of them are RNs and two are social workers. From what I understand, their services are not reimbursable by Medicare or any other health insurance. I’m not convinced of the value of their services.

The Affordable Care Act included some provisions for home care. For instance, the CLASS Act (Community Living Assistance Services and Supports) is a voluntary insurance program for home care through a voluntary payroll deduction plan. It was scheduled to go into place January 1, 2011. After a five year vesting period it would pay up to $50/day for non-medical services and supports necessary to maintain community residence. Currently, Congress is trying to repeal this act.

Helpful websites/blogs:

Health Affairs Blog, “Informal Caregiving by and for Older Adults” by Donna Wagner and Emiko Takag (Feb 16th 2010)

Aginginplace.com website and blog by Patrick Roden, RN, PhD

Aging Well Consortium website and blog by Liz Taylor, Seattle-area journalist and advocate on aging issues. An advocate of ‘intentional aging.’

Social Media and Nurses

Infographic on how Social Media are being used...
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Facebook, Twitter, blogging, and all the other social media tools, oh my! I have been wading through the realm of social media and health care, specifically as it relates to nurses. Who owns you? Who controls what you can say?  I am interested in this topic for many reasons. I am currently writing a book based on my work as a nurse practitioner providing health care to homeless people. Most of my chapters use a specific patient to illustrate larger issues related to homelessness. I have changed patient names, ages and other demographic data—but is that enough to protect identities? In narrative non-fiction, the use of ‘composite’ patients (blending aspects of more that one person in order to hide identities) is frowned upon—at least by purists with a journalistic bent. As a nursing professor, I assign classroom writing assignments relating to narrative medicine/nursing, encouraging students to use a specific health care experience (as patient, provider or family member) and to use that experience to illustrate and examine health care policy issues. I encourage other nurses who are already in practice to speak out about workplace issues as a way of advocating for policy changes. I maintain my own Facebook page, I Twitter and I blog on nursing and health policy, while I maintain my own practice as a family nurse practitioner and as a university professor. What can I say and not say both legally and ethically? What can any nurse say both legally and ethically?

Obviously I am not a lawyer, nor am I an expert on the nuanced legalities of social media, which seem to be amorphous. What I share here is what I have been able to cobble together from a myriad of sources.

Theresa Brown, RN who is a regular contributor to the NYT Well Blog states that HIPAA (Health Insurance Portability and Accountability Act of 1996) rules are easy once you know them: a patient can identify him or herself in whatever you write, but no one else can. (But how can you know that when you are writing it?) Theresa Brown writes about specific patients she works with as a staff nurse on a hospital oncology ward. She also writes about specific interactions she has with other hospital staff, including physicians. For her book Critical Care (harperstudio: 2010) she mixes up the patients by changing race or gender as a way of protecting identity. She can’t do that for her NYT essays for journalistic “truth” reasons, but then she doesn’t disclose a patient’s race, exact age, or physical appearance as a way to protect patient privacy. She states that the hospital she works for tried to get her to have all of her NYT Well Blog essays ‘approved’ by them before publication and she refused, stating that this requirement would not hold up in a court of law. I think that worked in her case because of who she is (for instance, she survived getting tenure at Tufts before becoming a nurse—plus she is writing for the NYT Well Blog). The hospital administration backed down, but they agreed that she would not name the hospital she works for. However, when she was invited to the White House to meet with President Obama during Health Care Reform debates, her hospital was eager to have her identify them as her employer. (see her article, “Nurse as Writer, Writer as Nurse” Clinical Journal of Oncology Nursing, 15(2) April 2011).

Hospitals are risk adverse and tend towards paranoid status. They like tapping into the power of social media for their own benefit, as a way of attracting potential (paying) patients. A rapidly growing number of US hospitals currently have some social media/Web 2.0 presence. Hospital social media staff members also scan other social media sites for any possible negative news items about their hospital, or any infractions of patient privacy by hospital staff that could lead to HIPAA violations and/or lawsuits. Hospital managers and other staff are encouraged to report possible infractions—effectively to rat on their co-workers over their social media use. The recently released 2011 AMA Policy: “Professionalism in the Use of Social Media” encourages physicians to self-police other physicians for unprofessional conduct on social media before resorting to ratting to “appropriate authorities.” The ANA has no policy or guidelines on professional use of social media for nurses.

Many hospitals now have policies restricting use of social media by staff, including residents and physicians. These restrictions range from the concrete/understandable, such as “don’t Tweet from the OR, or add a patient photo on Facebook, or friend a patient on Facebook” to the fuzzy “don’t say anything on social media that you wouldn’t say in a faculty meeting or to a member of the media.” From personal experience, I can say that the latter is highly subjective and not very helpful as a guide. Equally fuzzy is the “elevator rule:” don’t say anything you wouldn’t say on an elevator. That would depend upon the elevator location and whether or not you are on the elevator by yourself… Not a helpful rule.

HIPAA strikes fear into many a health care provider’s heart. The US Department of Health and Human Services (HHS) Office for Civil Rights can levy steep fines on hospitals and individual health care providers for knowingly or unknowingly breeching any of the myriad rules of HIPAA. The University of California at Los Angeles Health System has just agreed to pay a $865,500 fine and add corrective actions in a case where employees viewed electronic medical records of two celebrity patients (for non-patient care reasons). Individual health care providers can be assessed a $50,000 fine and up to a year in jail for knowingly disclosing individually identifiable patient information. Health care providers (mostly nurses and ‘below’) can and have been fired from hospitals and clinics for HIPAA violations.

Just what is individually identifiable patient information? Having read the fine print of HIPAA (available on the HHS website), this includes the obvious date of birth/death, address, Social Security number, fingerprints/other biometric identifiers, and medical record number—to the less obvious age (OK to use an age of a patient up to age 89—after that you need to use ‘age 90 or older’). These unique identifiers have to be removed for individual patients, as well as for “relatives, employers, or household members of the individual.” The HIPAA privacy rule protects all individually identifiable health information “or information for which there is a reasonable basis to believe can be used to identify the individual.” This last stipulation of the privacy rule is where it gets fuzzy and where paranoia can set in.

In 2007 a group of medical bloggers got together to form the Healthcare Blogger Code of Ethics. It acknowledged that bloggers in the medical field have unique legal, ethical and professional challenges to blogging. The code was also developed in response to many medical bloggers being pressured by employers or academic institutions to stop blogging or face consequences, including termination. The code included issues of transparency (limiting anonymous blogging), commercial disclosure, civil discourse/courtesy, reliability of information/citing sources, and patient confidentiality. They developed a system for medical bloggers to apply for membership, be screened for ‘certification’ and then if they passed they could place the Healthcare Blogger Code of Ethics seal on their website to reassure readers (and employers).

I applaud HIPAA and its emphasis on increased patient privacy and security of health care information. I value the privacy of my own health care information. As a health care provider, I honor the trust patients need to have within the health care encounter. Egregious breaches of patient privacy by nurses and others on the health care team are rare, but need to be dealt with quickly and severely. But what concerns me is how HIPAA—as it is broadly interpreted by risk-averse hospital administrators—is further silencing nurses, and hindering their involvement in constructive health policy discourse. We need a more uniform, sane, and concrete guideline on patient privacy and health care providers’ use of social media.

Some resources:

The Healthcare Blogger Code of Ethics seems to be migrating from Blogspot to WordPress, so their website information isn’t currently available or I’d link to it here.

AMA Policy: Professionalism in the use of social media

“When Facebook goes to the hospital, patients may suffer: Social networking sites can bolster the image of medical facilities, but privacy standards can easily be violated.” By Molly Hennesey-Fiske. The LA Times, August 8, 2010.

 

Why Nursing Care Plans Refuse to Die

Social Security: Public Health nursing made av...
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Today I was simultaneously searching for appropriate guidelines for case study presentations for nursing students working in public health settings, and wondering where nursing care plans came from. The two seemingly disparate threads of inquiry converged in a stranger than fiction way.

The earliest origins of the nursing care plan seem to be attributed to Ellen L. Buell, a public health nurse and nursing instructor at Syracuse University, NY in the 1930s and 40’s. In 1930 in the American Journal of Nursing, she published an article: “The Case Study: As a Method of Teaching Students and Graduates the Principles of Public Health Nursing.” She presented the public health case study as a way of teaching comprehensive and systematic thinking and care planning to new nurses. It was based on home nursing, so included all the family members, their health status, socioeconomic status, housing conditions, and nationality/citizenship status. Some of the nursing diagnoses she uses are shyness and temper tantrums (for the children). Recommended nursing interventions include more fresh air and play out of doors. Her public health nursing case study approach then led to a codification of nursing theory, nursing process, nursing diagnoses and the nursing care plan. The development of all of these occurred within baccalaureate nursing programs. Nursing care plans originally were considered ‘higher thinking’ and planning possible by BSN prepared nurses, and were also meant to guide delegation of nursing duties to the ‘lesser’ diploma-trained and LPNs.

Nursing care plans took on a life of their own in the 1960s and 70s in the US, and then spread virally to other parts of the planet. They became an established requirement within BSN programs, as a way of indoctrinating nursing students into thinking like a nurse. Nursing care plans were a way of differentiating nursing practice from medical practice. All of the current nursing faculty in our country had to do 6-page nursing care plans in nursing school—it is an unquestioned part of becoming a nurse, so it is continued.

What is amazing is the lack of any evidence to support the usefulness of nursing care plans, either to teach nursing students systematic thinking, or to improve patient outcomes. And nursing care plans are not required for hospitals or long-term care facilities by the Joint Commission for certification. Interdisciplinary care planning and coordination is a Joint Commission requirement, but not nursing care plans. Nursing is the only health care discipline to continue to insist on having its own separate care plans.

Most nursing students abhor nursing care plans and find them simply busy work. Most real nurses out there practicing in hospitals and long-term care facilities find them tedious, and say they detract from and don’t aid good patient care. The advent of EMRs and electronic checklist nursing care plans have streamlined the process to some degree. Luckily, public health nurses—who started this whole crazy nursing care plan idea in the first place—don’t do nursing care plans.

Most useful relatively recent article I found on this topic was: Interdisciplinary Care Planning and the Written Care Plan in Nursing Homes: A Critical Review, by Mary Ellen Dellefield, The Gerontologist, 2006, 44(1): 128-133.