God’s Will Scale

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?

In (Nurses) We Trust

Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.

The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1^st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.

The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?

First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?

If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.

Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.

I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?

Violence at Work

This past week our local public radio station, KUOW, ran a series on workplace safety in Washington state. For those of you not familiar with Pacific NW-specific high-risk jobs, these include loggers and commercial fishermen, including scuba-diver harvesters of geoducks (world’s largest clams/highly priced aphrodisiac in China and Japan—when you see a photograph of one you’ll understand why). Then there are the non region-specific high-risk jobs of police officers, corrections officers and security guards.

But the highest risk job category of all in Washington state is that of nurses’s aid, followed closely by RN. The highest risk place to work is Western State Hospital. Nurse’s aids, nurses, and other frontline workers at Western State Hospital are assaulted on the job 60 times more than the average worker in Washington state. Western State is the largest psychiatric facility west of the Mississippi and houses criminal defendants when they are found mentally incompetent to stand trial. So it is in effect a combination correctional and psychiatric facility with highly volatile and violence-prone patients.

Nationwide, nurses working in Emergency Departments (EDs) are at high risk for workplace violence, generally in the form of physical violence from patients, family members or other visitors. EDs and urgent care centers are where people go for violence-related injuries stemming from domestic violence or gang violence. EDs and urgent care centers are where people go who are intoxicated or having acute psychiatric emergencies—usually accompanied by police. Waiting room overcrowding, long wait times to be seen by a provider, lack of visible security systems, lack of staff training on de-escalation techniques, and understaffing, all contribute to increased risk of violence. Reports from around the country indicate a steady increase in ED violence, most likely stemming from weakening primary care safety net services, forcing more desperate and frustrated patients into EDs for basic health care needs.

The KUOW episode “Violence in the ER” and the accompanying Seattle Times article “Most violent job in Washington? Nurse’s Aid” highlight ED workplace violence in Tacoma General Hospital in Tacoma, and Harborview Hospital in Seattle—the state’s two biggest hospital EDs. Tacoma General Hospital ED uses a metal detector at all times to screen patients and visitors. Harborview Hospital only uses a metal detector in the ED at night, and at other times security guards use a hand-held metal detector on patients and visitors they deem high risk. Harborview Hospital administrators, like many for hospitals across the country, have chosen not to install permanent metal detectors for fear of slowing down emergency care. According to the KUOW report, on a recent Saturday night a man got into the Harborview ED with a backpack containing a large knife, two cans of pepper spray, a cap gun, and bullets.

Third behind ED and psychiatric hospital settings for workplace violence for nurses is home care/home hospice. Work in these settings is usually done solo, with possible exposure to domestic violence or drug activity.

The Occupational Safety and Health Administration (OSHA), the federal agency charged with ensuring safe and healthful working environments for US workers, has failed to issue federal standards on workplace violence in health care settings. So far, they have only published voluntary guidelines on this topic. California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed state laws requiring further protection for health care workers. For instance, in Washington state, all health care settings are required to develop and implement plans to protect employees from violence. State law now makes it a felony for anyone to attack a health care provider—including verbal threat of assault. Washington state law requires all health care settings to keep records of any violent act (including verbal threats) against an employee, patient or visitor.

According to Jeaux Rinehardt, president of the Washington State Emergency Nurses Association, the felony assault charge is mainly enforced for attacks on doctors—rarely for attacks on nurses or other health care providers. He also echoes many nurses around the country in stating that nurses are actively discouraged from reporting and documenting workplace violence by managers or hospital administrators. (KUOW News: Violence in the ER, 7-13-11)

I worked in home health in Richmond and Baltimore for seven years during the height of the crack cocaine epidemic of the late 1980’s/early 1990’s. I worked in a large downtown Baltimore hospital urgent care center for six years. If you have watched any episodes of “The Wire” that’s what it was like to work and live in Baltimore at that time. The worst thing that happened to me during those years was that an intoxicated patient peed on me during a pelvic examination right when we had a power outage. She got scared she said, so it’s not like she meant any harm. The urgent care center I worked for was well staffed, had excellent relations with the community it served, and had a visible, well-functioning security system. We had panic buttons we carried in our pockets at all times, but I never had to use it. All staff received regular training in violence prevention techniques.

By contrast, working at various community health centers in and around Seattle for 15 years, there were at least ten times when patients seeking narcotics verbally or physically threatened me. These clinics were usually poorly staffed, served large numbers of impoverished people, had no security systems in place, and did not have clear protocols or “pain contracts” for use of narcotics. I remember front desk staff calling for police in several of the cases, but I think in only one case was I encouraged to complete an Incident Report.

An aspect of workplace violence in health care settings I had not even thought of appeared as a spin-off of a KevinMD.com guest blog. In 2007 Patricia Allen, RN wrote “Violence in the Emergency Department and how to promote ER safety.” It is a short blog post, mainly advertising her book. What I found more interesting was a reader’s comment. Steve Parker, MD: “Here in Arizona, hospitals are gun-free zones. Most physician and healthcare providers will not carry their guns into the hospital. Risk of getting caught is too high.” I had to read his comment twice before I understood it, because it never occurred to me that health care providers would carry concealed weapons to work. I thought that was confined to really bad TV shows.

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