God’s Will Scale

The One Slide: End of Life Questions
The One Slide: End of Life Questions (Photo credit: stevegarfield)

It’s official: they have a research scale for everything, including God’s Will. In dealing with my elderly father’s illness and end-of-life (EOL) decision-making/interface with the health care system, I kept remembering research I’d read about religiosity and EOL choices. Higher religiosity is associated with preference for life-prolonging medical treatments. This may seem counterintuitive at first, but perhaps people with higher religiosity are less likely to doubt the limits of medical science and our health care system. Researchers developed the Gods’ Will Scale to measure degree of religiosity (Winter, et al, 2009, Preferences for life-prolonging medical treatments and deference to the Will of God, J. Relig Health. 48: 418-430) The New York Times today has an interesting Opinion piece related to this topic: Why Do Americans Balk at Euthanasia Laws?  Contributors to this article point to the fact that the US population scores much higher on religiosity scales than do our peer nations. I should mention again that my father is a retired Presbyterian minister living in the conservative and highly religious state of Virginia.

I praise God and every other possible Higher Being that I live in a relatively enlightened state—that state being Washington State, which joined Oregon in the Death with Dignity Act. We also have a relatively active and from what I hear effective POLST Paradigm program: Physician Orders for Life-Sustaining Treatment Paradigm. POLST Paradigm program is designed to improve the quality of care people receive at the end of life. As they describe the program “It is based on effective communication of patient wishes, documentation of medical orders on a brightly colored form and a promise by health care professionals to honor these wishes.” From what I understand, POLST was started in response to complaints from patients that their EOL wishes as declared on Living Wills/Advance Directives were not being honored within the health care system. There have been cases of patients tattooing “DNR” (Do Not Resuscitate) on their chests in an attempt to have their wishes honored. Supposedly this works as long as rescue personnel bother to read their tattoo.

On the POLST website they describe patient-centered end-of-life care as, “Effective communication between the patient or legally designated decision-maker and health care professionals ensures decisions are sound and based on the patient’s understanding their medical condition, their prognosis, the benefits and burdens of the life-sustaining treatment and their personal goals for care.”

All people over the age of 18 are advised to have a Living Will/Advance Directives. In addition, people with a life-limiting illness should have a POLST. In Washington State POLST forms can be signed by physicians, nurse practitioners or physician assistants–that, of course, varies state to state according to their scope of practice regulations. Virginia has not yet adopted the POLST Paradigm.

In my opinion, my father has not received patient-centered end-of-life care. Instead, he received costly life-sustaining medical treatment and remains hospitalized in ICU. But at the same time, he is up and walking with help, complaining about the hospital food, and ready to get back to his work of taking communion to people in nursing homes. So, maybe it’s God’s will?


Angel with mobile phone
Image by Akbar Sim via Flickr

Recently, I was in a hospital elevator when three hospital employees walked up to it separately, all deeply concentrating on their smartphones. Their smartphones collided, and they looked up dazedly, sheepishly apologizing as they stepped on to the elevator. Then all three resumed communing with their smartphones. From where I stood I could see that at least two of them were not doing patient or work-related activities on their phones. I considered this research and not elevator eavesdropping.

By now everyone has heard of the dangers of cell phone and texting distraction while driving, although state laws banning or limiting cell phone use while driving seem to be scoff laws. Being a true Seattleite, I bike to work on our lovely Burke-Gilman bike trail. This used to be almost idyllic but now I have to watch for bikers on their phones, weaving as if they’re drunk. I am not a complete curmudgeonly Luddite: I own an iPhone, but I don’t use it while riding my bike, driving, or walking onto a hospital elevator.

A recent NYT article on distracted doctoring and distracted nursing highlights the extent of hospital personnel using smartphones, computers and other electronic devices for things other than work, including when they are doing patient care—even when they are doing surgery. (“As Doctors Use More Devices, Potential for Distraction Grows” by Mike Richtel, 12-14-11). A neurosurgeon reportedly was talking on his cellphone (using a wireless headset) during a surgery that got botched, leaving the patient partially paralyzed. An OR nurse in Portland was reprimanded for surfing an OR computer for airfares while she was covering a spinal surgery. And then for the truly frightening, over half of 439 technicians surveyed admitted to texting while monitoring heart bypass machines.

When my father was in the hospital last year, I noticed that his nurses spent much more time on the mobile computer stations outside of his room than they did in direct patient care. He had some terrific nurses, and they told me that they hated how much time they had to spend in checking and entering patient data in the computers. The legitimate use of technology in health care is all in the name of patient safety. But at what cost does it come in terms of the human interaction necessary as the core of all healing?

The angel statue in the photo is on a cellphone…

Burnout and Crazy Cat Ladies

Image by Rakka via Flickr

Question: What do professional burnout for nurses and crazy cat ladies have in common?

Answer: Pathological altruism.

This, according to a recent NYT book review “The Pathological Altruist Gives Till Someone Hurts.” (Natalie Angier, 10-3-11). The book is an anthology entitled Pathological Altruism  (Barbara Oakley, et al, editors/ Oxford University Press) due out December 2011. Altruism—behavior aimed at helping another person. True altruism is said to spring from empathy (vs. self-interested egoism). Authors included in this book link pathological altruism to animal hoarding, anorexia, personality disorders, codependency, and professional burnout for health professionals—especially nurses.

Barbara Oakley seems to have gotten the idea for this anthology while she was researching and writing her somewhat creepy (among other things—a cover photo of a black-widow spider), cumbersomely titled book Cold-Blooded Kindness: Neuroquirks of a Codependent Killer, or Just Give Me a Shot at Loving You, Dear, and Other Reflections on Loving That Hurts (Prometheus Books, 2011). A pseudo-scholarly take-off on Capote’s In Cold Blood, her book examines the story of Carole Alden, a Utah artist who killed her husband in what she claims was self-defense/Battered Woman’s Syndrome—but who was sentenced to 15 years for manslaughter. A collector of animals (and of drug-addicted men), Carole was known for her compassion.

But Oakley contends that Caroles’ type of compassion is an example of diseases of caring, of empathy gone awry. She quotes research by Jean Decety, a University of Chicago scientist who examines the neural pathways that underlie empathy. According to Decety, empathy has four components. Empathy is a mixture of all four, and if any one of them gets distorted—by genetics, developmental issues, or stress—empathy can become pathological. Decety’s four elements of empathy are:

1)   ability to share someone else’s emotions

2)   awareness of yourself and other people—and knowledge of where you “end” and where others begin

3)   the mental flexibility to set your own perspective aside and view things from another person’s perspective

4)   the ability to consciously control your emotions. (as quoted pg 57 Cold-Blooded Kindness)

Empathy can either lead to compassion/acts of kindness, or it can lead to empathic distress when the suffering of others becomes or compounds our own suffering. Empathic distress is something that nurses are particularly prone to, leading to burnout. There are empathy brain cells (of course!) called mirror neurons located in the right frontoparietal lobe—in left-handed people. And they’ve identified this area as being active when health care professionals are able to emotionally distance themselves from images and sounds of a patient’s pain and suffering. Researchers are looking at ways of teaching health care providers to be able to emotionally distance themselves “just enough” to protect themselves, while still providing compassionate care. A different kind of Universal Precautions.

In the NYT article referenced above, Angier writes, “Train nurses to be highly empathetic, and, yes, their patients will love them. But studies show that empathetic nurses burn out and leave the profession more quickly than do their peers who remain aloof.”

We know that educating nurses to be aloof Nurse Ratcheds isn’t the answer to burnout prevention. I think that a lot of what is called burnout in nurses is really moral distress: wanting to do the right thing by a patient, but being blocked by factors in the health care system that are outside the nurse’s control. And for prevention of real burnout in nurses, I think we can do a better job in nursing education—by helping students (and ourselves) examine and process the sometimes complex and unsavory motivations for ‘doing’ nursing. Otherwise we will continue to graduate burnout-to-be nurses, along with future crazy cat ladies (and lads).

Doctor, Doctor, Nurse, Doctor

US Navy 031027-N-0000W-001 Family Nurse Practi...
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We just want to be doctors without having to go to medical school. Yes, that’s it.  I want to be called Doctor Nurse Ensign—or maybe Ensign Doctor Nurse if I ever work in the Navy and want to really confuse people.

Disclosure: I have a master’s degree preparation for being a Family Nurse Practitioner, with a practice doctorate in public health, a DrPH. The DNP—Doctor of Nursing Practice—the newish practice doctorate in nursing—did not exist when I went to nursing school. I am quite happy with my combination of alphabet-soup letters/degrees given my focus on health policy for marginalized populations. If the DNP had existed when I went to nursing school—and if it had been the only option for becoming a nurse practitioner—I suppose I would have done that but still obtained my MPH—Master of Public Health. The two disciplines complement each other well. In my experience, the MPH provides more uniform, concrete, and useful skills than does any degree in nursing—even the DNP in its current incarnation.

Earlier this month there was a NYT article entitled, “When the Nurse Wants to Be Called ‘Doctor’” (by Gardiner Harris, 10/2/11).  It is an excellent, well-balanced article. I also recommend the Well Blog version with interesting reader’s comments/ a longer blog post by Barbara Ficara on the Healthcare Blog.) The NYT journalist discusses how nurse practitioners are moving towards having DNP’s as entry to practice and are asking to be called doctor. Harris writes, “Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title ‘doctor,’ but also the money, power and prestige that often come with it.”  Pharmacists moved to entry-level practice doctorates in 2004, and physical therapists are moving towards it as well. He says that nursing leaders say the push for the DNP has nothing to do with their fight for expanded scope of practice and higher salaries for advanced practice nurses—but rather with the pressures to keep current because “knowledge is exploding.” Not surprisingly, many physicians are fighting back. Physician lobbying groups around the country are pushing for increased state and federal legislation restricting anyone without a MD or DO (doctor of osteopathy) from using the title ‘doctor.’

As Harris points out in his article, there are no data to support the value added of a doctorate over a master’s degree in terms of quality of care provided by nurse practitioners. And it takes one to two years longer to obtain a DNP vs. a master’s degree. Health economists are concerned this can translate into increased costs for patients and longer wait times to access primary care providers. This disturbs me since the nurse practitioner role was developed specifically to help address access to care issues for the poor, the elderly, rural, and other marginalized populations. It is why I chose to become a nurse practitioner.

Who are you?

Gargoyle by Dudley Pratt on UW's Smith Hall
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This was the greeting Dr. Joan Shaver, PhD, RN, FAAN threw Theresa Brown’s (PhD, RN) way last night when I introduced them to each other. Theresa could, of course, have asked Joan the same question, except that we had both just finished sitting through Joan’s 90 minute lecture on the future of nursing—so Theresa knew the answer. Dr. Shaver is Dean of the Arizona State College of Nursing and gave the Soule Endowed Lecture for the University of Washington School of Nursing. Her lecture, entitled “Nursing Science and Practice: Working Together to Benefit Patients and Communities” included many PowerPoint slides—along with the seemingly required two-part:title. Her talk immediately preceded the Nurses Recognition Banquet, at which Theresa Brown was the guest speaker. Theresa Brown, as most of you probably already know, is an oncology nurse, regular contributor to the NYT’s Well Blog, and author of Critical Care: A New Nurse Faces Death, Life, and Everything In Between (HarperStudio, 2010). Especially with the national attention paid to her recent NYT’s Op-ed piece, “Physician, Heel Thyself,” Theresa is a major voice for nursing in our country. Dr. Shaver had no idea who she was. To bear witness to this collision of nursing worlds was one of the most interesting things of the entire day for me. It dismays me, since it highlights just how out of touch nursing academia is with the real world of nursing—and of nursing advocacy.

Hubris was present in abundance. At the beginning of the series of talks and awards, Dr. Marla Salmon greeted the audience and began to introduce herself as “Dean of the United States.” She caught herself mid-United States and corrected it to Dean of the University of Washington School of Nursing. Dr. Shaver peppered her talk with photos of nursing leaders she has worked with—all older white women. In contrast, Theresa Brown was grounded, humble, and gracious. Dr. Shaver’s talk focused on broad-stroke theories and recommended directions for nursing research and practice: scaling up nurse-managed clinics, group vs. individual patient clinic visits, and having a community-based vs. hospital care emphasis. Theresa Brown’s talk focused on bottom up vs. top down change, and a move towards universal BSN-prepared RN’s as a way of strengthening nursing. Theresa also admonished us all to hold each other and ourselves accountable for collegiality and to stop nurse on nurse bullying—to stop perpetuating the reality behind the saying “nurses eat their young.” She ended by stating that nursing needs more of a public voice and that is the responsibility of all of us—to speak up about what nurses do.

Dr. Shaver ended her talk with a cartoon showing a seated older, grumpy-looking woman. The caption read, “The reason you can’t fool all the people all the time is because half of them are women.” Beside this caption she had added, “and many of them are nurses.” She did preface this slide by giving an apology to any male nurses in the audience, “but nursing is still mainly a female dominated profession.” As if that made it OK? The old girl’s network of nursing leadership in this country has to change. We do not need the next cohort of old girls to perpetuate the path they are on.

At the end of the Nurses Recognition Banquet last night we toasted to nurses. Cheers. Salud, dinero y amor. Bottoms up. Secretly, I toasted to bottom up change in nursing.

Re-scripting Code Pink

Marching in 2004.
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I worked at a community health clinic that was housed in an old restored firehouse with old plumbing designed for a few firefighters and not for hundreds of patients each day. We fairly regularly had “Code Brown” called over the clinic loudspeaker when the sewer system backed up into clinic areas. Sometimes they closed the clinic until it was cleared. Sometimes we worked around it. That’s community health.

I have never worked where they called “Code Pink” and I think I am glad of that. It sounds as if it should be a mammogram emergency. According to nursing leadership expert, former Dean of the Kansas School of Nursing, and current hospital mystery writer Eleanor Sullivan, Code Pink is called by a nurse in a hospital who is being bullied by physicians or others. In her letter to the NYT editor in today’s paper (Sunday May 15th), she writes, “The word is passed nurse to nurse, and colleagues gather around the beleaguered nurse. Few physicians can stand the scrutiny of neutral-faced nurses standing silent beside one of their own.” Somehow I don’t picture the nurses as neutral-faced. All four letters today in “When Doctors Humiliate Nurses” were supportive of Theresa Brown’s Op-ed article “Physician Heel Thyself.” All four letters were relatively bland, especially compared with the responses to her article found elsewhere.

Dr. Kevin Pho on his popular blog KevinMD.com, has already written two posts on Theresa Brown’s article. In his first blog post entitled “Theresa Brown unfairly blames doctors for hospital bullying” he states, “Brown has a prominent media platform in the New York Times, and, in a way, she wields it here to metaphorically bully the entire physician profession.” Many self-identified physicians who responded to Dr. Pho’s blog post were supportive of his read of Ms. Brown’s articles, although most stated they refused to (literally) read anything she writes… One person identified as “David MD” did the math, dismissed Ms. Brown as a neophyte nurse since she has a pre-existing PhD and pre-existing children, and admonished her for “extracurricular writing” that “must have violated the terms of her employment at Shadyside Hospital.” He concludes, “From the tone of her other blogs, she must be an absolute nightmare to work with.” David MD stated that he had written a letter to the editor of the NYT in protest of her article.

In his follow-up blog post, “Doctor bashing and confronting physicians in the media,” Dr. Pho admitted that Ms. Brown’s article had brought the topic of hospital bullying into the national health care conversation. He applauded her for bringing up such a difficult topic in the NYT. But he still takes issue with her method, calling it an “adversarial approach,” and alluding to it as “doctor bashing.” He even likens it to the case of the Seattle nurse Kim Hiatt being fired by Children’s Hospital for a medication error, stating that neither will solve larger systemic issues within health care. Instead, for physician bullying, he places blame on the medical education system for perpetuating the socialization of arrogance and bad manners in medical students. That line of reasoning makes no sense to me: Medical education is by and for physicians.

What I find fascinating in many of the physician blog posts and comments to Ms. Brown’s article, is the resentment that, 1) she is a nurse and she can write well, and 2) she has a national media platform through the NYT. In his second blog post on Ms. Brown’s article, Dr. Pho writes, “Brown is a former English professor, and it’s no wonder that the framing of the piece is masterful.” Some of the posts by physicians call for her hospital administration to silence her. In Ms. Brown’s recent article entitled “Nurse as Writer, Writer as Nurse” published in the Clinical Journal of Oncology Nursing (April 2011), she acknowledges that dealing with hospital management has been tricky when it comes to her writing. She never identifies the hospital where she works, although as she says it’s easy enough to figure out who her employer is. She states that when she first started writing, the hospital management wanted editorial control over everything she wrote. “Knowing this was a request they could not legally make, I said, ‘No,’ and have had to repeat this refusal more than once. It’s not always easy, and at times I wasn’t sure I was tough enough to stand up to the healthcare corporation I work for.” I do not know what sorts of blowback Ms. Brown is currently getting from her hospital administration over her NYT Op-ed article “Physician, Heel Thyself.” But if she is feeling this heat, perhaps she could call a Code Pink of the Dr. Sullivan type. I contend that she has done vastly more through her ‘popular press’ writing to effect positive change in nursing and health care than any amount of academic journal articles or IOM reports or White Papers.

For those of you in the Seattle-area, Theresa Brown will be speaking at a public event next week at the University of Washington. Sponsored by Poets and Writers and the School of Nursing, Ms. Brown will give a talk entitled “Nurse as Writer, Writer as Nurse,” UW Health Sciences, Room T-625, Thursday May 26th 10:30-12:20pm. The following is the blurb I wrote to describe the event:

Theresa Brown is an oncology nurse, author of Critical Care: A New Nurse Faces Death, Life, and Everything in Between (harperstudio, 2010), and is a regular contributor to the New York Times’ Well blog. In a recent article entitled “Nurse as Writer, Writer as Nurse” in the Clinical Journal of Oncology Nursing, Ms. Brown addresses the most common questions people ask her, such as, “What about patient confidentiality?” “Do you take notes at work?” and “How do your coworkers (and employer) feel about your writing?” A former English professor who found her true calling as a nurse, Ms. Brown will talk about her dual paths as writer and as nurse.

Narrative Nursing

Cover of "Narrative Matters: The Power of...
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The health policy journal Health Affairs has a feature entitled “Narrative Matters,” which are personal essays in the voice of patients, their families and caregivers with a health policy aspect. Health Affairs has been running these essays for 10 years and is a popular feature, crossing over to news features on NPR and in the New York Times. In 2006, the editors of Narrative Matters published a book collection of 46 of their best essays. The essays included in the book are all very powerful. They range from a former governor writing about the culture clashes between medicine and public policy, to a physician’s struggle to care for his father with dementia. What struck me as I read these essays, as well as the other more recent ones available online, was the fact that very few were by nurses. In the book version, there are two essays written by nurses. They are both by male nurses and deal with their moral distress, burnout, and decision to leave nursing. This is a common problem in nursing, and rates of burnout and exit from nursing are much higher for male than for female nurses. It’s good to have their perspectives on the issues voiced, but was disappointing that those were the only essays by nurses included. Of the 10 essays published in 2010, seven were by physicians, two were by patients, and one was by a nurse practitioner. The nurse practitioner wrote about her decision not to have mammograms and the negative reactions she gets when she voices her decision and rationale. We need more nurses writing these sorts of essays, and having them published in high profile journals such as Health Affairs. Publishing in nursing-specific journals is all well and good, but I don’t think many nurses ever read them, and the general public most certainly does not.

Next quarter I am teaching a graduate level course in health politics and policy and in lieu of a course paper I am having students write (and submit) policy-level nursing narratives for Narrative Matters. So stay tuned to Narrative Matters for (hopefully) some stronger nursing voices.