The Opioid Epidemic – Why we need to dial back the sensationalism and find common-sense solutions

Here’s my latest article in Working Nurse Magazine –

One of nurses’ most important and underappreciated duties is advocating for our patients. While much of that advocacy takes place at the bedside, we are also in a unique position to address the larger issues that affect the practice of nursing and medicine.

The latest issue that demands our attention is the controversy over prescription opioids and the efforts of the Medical Board of California to crack down on these dangerous but necessary medications.

THE PERILS OF STATISTICS

If you listen to the fearless pundits of the Fourth Estate, deaths related to prescription drugs are a national crisis. According to the Centers for Disease Control and Prevention, 38,329 Americans died of drug overdoses in 2010 and about 60 percent of those deaths involved prescription medications, many of them opioids.

Back in 2012, the Los Angeles Times ran a four-part investigative report on the human cost of opioid abuse and the role of some physicians in overprescribing painkillers. The story reported that between 2006 and 2011, there were 3,733 deaths related to opioid use in just four Southern California counties: Los Angeles, Orange, San Diego and Ventura. That story and others like it have put pressure on the Medical Board of California to respond to the growing “epidemic.”

I put the word “epidemic” in quotes because the outcry is somewhat out of proportion to the reality. As alarming as the number of opioid-related deaths sounds in isolation, the L.A. Times report failed to contextualize that statistic in terms of the combined population of those four counties (16.9 million as of July 2011), the population of California as a whole (37.7 million) or the number of deaths due to other causes during the same period. For example, according to the California Highway Patrol, car crashes killed 18,416 Californians between 2006 and 2011: almost five times the death toll of the headline-grabbing opioid menace.

PSE AND THE METH EPIDEMIC

I don’t mean to diminish the significance of those deaths or suggest that there isn’t a problem, but it’s important not to let alarmism triumph over common sense. While the number of collision-related deaths may indicate a need for better traffic safety, no one is seriously suggesting closing our freeways or restricting how far commuters are allowed to drive!

Unfortunately, when it comes to drugs, such overreaction is the rule rather than the exception. For instance, many of us are familiar with the federal Combat Methamphetamine Epidemic Act of 2005 (CMEA), which sought to stem the rise of methamphetamine abuse by restricting the sale of products containing the nasal decongestant pseudoephedrine (PSE).

PSE is not a prescription drug in most states, but the CMEA limited how much PSE a customer could buy at one time, mandated behind-the-counter placement in stores, required photo identification for purchase and forced sellers to maintain logbooks of sales and customer information. Those measures have had little impact on the meth epidemic. At a conference this February, DEA Office of Diversion Control Deputy Assistant Administrator Joseph Rannazzisi admitted that “NEITHER of these systems [tracking or rescheduling PSE] will have ANY impact on methamphetamine availability in the United States.” [emphasis in the original]. In short, these restrictions  have not curbed the meth supply, but have added a considerable bookkeeping burden for retailers while inconveniencing millions of cold and allergy sufferers.

The effects of the state medical board’s response to the outrage over opioid-related deaths may be far worse. Some of the suggestions I heard at a recent meeting of the board’s Prescribing Task Force left me wanting to tear out my hair in frustration.
the role of alcohol

California’s medical community has good reason to be embarrassed by the L.A. Times expose, which linked a substantial number of overdose deaths in Southern California to a surprisingly small number of doctors.

The story also raised serious questions about the medical board’s effectiveness in responding to complaints about excessive or reckless prescriptions. The board seldom suspends a doctor’s prescribing authority even if he or she is being actively investigated or has already been disciplined for reckless prescribing.

Given all that, you might expect that the Prescribing Task Force’s focus would be on improving the medical board’s oversight of its own members. Instead, I listened to hour after hour of experts proposing new restrictions on patients. The suggestions ranged from requiring patients to sign a contract with their physician prior to receiving prescription opioids to forcing all patients to submit to pill counts and random urine tests. Such measures would be tantamount to treating patients like criminals!

There were more sensible proposals calling for greater patient education, but overall, I was dismayed by the lack of clear-headed perspective on the issues involved. For example, one expert pontificated at length about the evils of opioid abuse without once mentioning the role of alcohol in many painkiller overdose cases. When I asked him about it, he replied that he would touch on that point at the end of his presentation, suggesting that he considered alcohol a trivial footnote rather than a significant contributing factor in many overdose deaths.

PUTTING PATIENTS LAST?

As a nurse and as one of the estimated 100 million Americans living with some degree of chronic pain, I am well aware of both the power and the dangers of opioid painkillers. There’s no argument that opioids carry a high potential for abuse and can kill if misused.

However, I’ve also witnessed the consequences of overzealous protocols that prevent patients from getting needed medication. If you suffer chronic pain, draconian limits on how much painkiller you’re allowed do not protect you; they just reduce your ability to function and increase the chances that you’ll find some other way to self-medicate — possibly with lethal consequences.

Tools like pill counting or contracts may be appropriate in certain cases, but imposing such restrictions on all patients would only have a chilling effect on the provider-patient relationship. If our approach to patients defaults to suspicion and mistrust, we only discourage our patients from communicating openly with us about issues like abuse and addiction.
comprehensive approach

So, what should be done? A better solution would include all of the following:

  • Improved education for patients about the dangers and proper use of opioids, including the risk of adverse interactions with alcohol or other drugs.
  • Better educating physicians and their healthcare teams about the signs of opioid abuse, including how to recognize potential risk factors like addictive personalities.
  • Fully implementing a real-time prescription drug monitoring program that can flag suspected prescription shoppers and physicians who may be recklessly prescribing opioids or running “pill mills.” California’s CURES (Controlled Substance Utilization Review and Evaluation System) could be but currently isn’t used for that purpose due to a lack of resources and interest.
  • More effective sanctions for doctors whose prescription history suggests a pattern of reckless or inappropriate prescribing.
  • Finding and funding alternative treatments for chronic pain and conditions that cause it. If you remove the source of the pain, you also remove the need to treat it with opioids.

Obviously, many of these are long-term solutions. In the short term, it’s important that nurses get involved in the debate. The Prescribing Task Force’s next meeting is in May. (See www.mbc.ca.gov for a schedule.) The meetings are open to the public and I urge readers to attend and participate.

This is an issue that directly affects many of us, our loved ones and our patients. We should not sit idly by while the medical community devises quick-fix solutions that may ultimately do more harm than good.

Genevieve Clavreul’s earlier article on this topic, “The Great Opioid Debate of 2012,” was published in WN127, Sept. 3, 2012.

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Scott Glover and Lisa Girion, “Dying for Relief: A Times Investigation,” Los Angeles Times:

Part 1 (“Legal Drugs, Deadly Outcomes,” 11 Nov. 2012)

Part 2 (“Reckless Prescribing, Lost Lives,” 9 Dec. 2012)

Part 3 (“Rogue Pharmacists Feed Addiction,” 20 Dec. 2012)

Part 4 (“Unused Tool Could Help State Flag Deadly Doctors,” 30 Dec. 2012)

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CDC, “Drug Overdose in the United States: Fact Sheet,” last updated 10 February 2014. The fact sheet says 60 percent of 2010 overdose deaths were pharmaceuticals, of which 75 percent involved opioids and 30 percent involved benzodiazepines.

Physicians for Responsible Opioid Prescribing, “Cautious, Evidence-Based Opioid Prescribing.”

The American Academy of Pain Management, cites 100 million chronic pain sufferers in America, per Institute of Medicine Report, “Relieving Pain in America.”

Transforming Prevention, Care, Education and Research (Washington, D.C.: The National Academies Press, 2011.

Anatomy of a BRN Complaint and DUI Investigation

What to expect and when you need a lawyer

By Genevieve M. Clavreul, RN, Ph.D.

The mere mention of an investigation by the California Board of Registered Nursing (BRN) can strike fear into the heart of any nurse, and for good reason. A BRN investigation can turn your life upside down and even end your career.

With that in mind, I thought it would be worthwhile to explain what you can expect if you become the target of such an investigation.
by the numbers. Nurses can take some comfort in knowing that only a small percentage of RNs wind up in the BRN’s investigative sights each year.

Look at the Numbers

According to the BRN, there were 392,458 actively licensed RNs in California in September 2013. During the 2013 fiscal year (July 2012 through June 2013), the BRN’s Complaint Intake office recorded a total of 8,330 new cases, of which 7,714 were assigned for investigation.

The majority of last year’s new investigations — more than two-thirds — were initiated because the BRN learned that a nurse had been arrested for or convicted of a felony or misdemeanor related to his or her nursing duties or qualifications. The most common offense was driving under the influence (DUI).

Only 2,876 BRN complaints were filed by consumers in fiscal 2013 and 508 of those complaints were closed without an investigation. That means only about 0.6 percent of California RNs — one in every 163 nurses — faced a BRN investigation last year due to a consumer complaint.

First Steps

Let’s imagine that worse comes to worse and someone files a complaint against you. The BRN’s first step is to review the complaint to determine if it falls within the board’s jurisdiction. If not, the complainant may be referred to a more appropriate agency, but the case is considered closed as far as the BRN is concerned.

If the complaint does fall within the board’s purview, the next step is to determine if there is reason to refer you to the Diversion Program. This is a voluntary, confidential program for nurses struggling with mental illness or problems with drugs or alcohol. Obviously, that isn’t relevant in many cases and even if it is, the BRN may not offer you the option. Also, you can’t practice while you’re enrolled, so while the program might let you keep your license, you will probably lose your job.

If you aren’t offered that option or you decline, the board assigns the complaint for further investigation. Depending on the nature of the allegations, a complaint might be investigated by BRN staff, the Division of Investigation of the California Department of Consumer Affairs (of which the BRN is a part) or an outside investigator.
harsh questioning

Make no mistake — a BRN investigation can become a nerve-wracking examination of your professional and private life that makes a TSA strip search look like a friendly pat on the back.

Adding to the stress is the fact that investigators aren’t obliged to tell you exactly what they’re after or even the full details of the complaint. You won’t usually know who the complainant is or what they said, which can leave you scrambling to defend yourself without really understanding what kind of trouble you’re in.

BRN investigations are considered administrative actions, not criminal investigations, so many of the legal tidbits you’ve gleaned from watching TV dramas like “Law and Order” don’t apply here. Nevertheless, there are two rules that do apply: You have the right to remain silent and anything you say is likely to be used against you!

Call Your Lawyer

You are allowed legal counsel when speaking to the BRN investigators, and if you’re facing an investigation, hiring an attorney may be a wise move. Unfortunately, it can also be expensive. Many malpractice insurance policies don’t protect you in the event of a board complaint or will impose caps on how much the insurer will pay to assist in your defense. Still, if the investigation results in a formal accusation, your entire nursing career may be on the line, so the cost might well be worth it.

If you don’t know how to find a lawyer with expertise in this area of law, the American Association of Nurse Attorneys (www.taana.org) may be able to help. This is an association comprised of RNs who are also attorneys, many of whom have experience representing nurses in cases like these and understand both the legal and professional issues involved.

The Formal Investigation

An investigation is just that: examining the evidence related to a complaint to determine if it has any substance. Not all investigations result in an accusation, much less disciplinary action. Sometimes, investigators conclude that the allegations were false or at least that there is insufficient evidence to substantiate them. In other instances, the board might decide the allegations are substantiated, but opt to let you go with a citation and a fine.

If you’re not so fortunate, the board’s next step is to issue a formal accusation that you have violated the Nursing Practice Act. This accusation is public record and anyone can look it up on BreEZe or the BRN website. In most cases, the accusation will be followed by an administrative hearing, which is like a trial.

If you haven’t already hired a lawyer by this point, you should seriously consider doing so. Administrative hearings have their own terminology, rules and procedures; a simple misunderstanding could be career-ending. If you don’t promptly file a notice of defense after receiving the accusation — in which case the board will assume you’re forfeiting your right to a hearing — or if the board rules against you, you may be kissing your license goodbye. Depending on the allegations, you might even face criminal charges.

Keeping the BRN Fair

We like to think that the BRN represents nurses’ interests, so ending up on the receiving end of the board’s suspicion can feel like a betrayal. However, we should keep in mind that the BRN is not in the business of protecting RNs — it’s in the business of protecting the public from RNs!

If the BRN has reason to believe a nurse has stepped out of line, the public and our elected officials have every right to demand that the board act swiftly and firmly to investigate and correct the situation.

That doesn’t mean that nurses have to stand by helplessly or be railroaded. By educating ourselves on the BRN’s policies and disciplinary procedures, we can exert our influence to ensure that the board acts fairly and justly. BRN meetings, including the meetings of the Diversion/Discipline Committee, are open to the public and allow for public comment on any issue relevant to the committee’s business, even if the item isn’t on the agenda.  (You can find a schedule of meetings here.)

Another option, and one I always recommend for nurses, is to get involved with the legislative process. Remember, the BRN’s function is to enforce state law and regulations. If you feel those rules are unjust, it only makes sense to address your complaints to the lawmakers with the power to change them — or consider running for office yourself.

 

The Nursing Shortage Paradox in California

With more and more dire reports coming out about California’s growing nursing shortage, you would assume that our state desperately needs nurses. Nearly every day, my email inbox is besieged with messages advertising temporary and permanent nursing positions and a cursory search on one of the national nursing job boards returns more than 1,000 job openings.

However, if you read the forums on those same job boards, you’ll find post after post from nurses — mostly new graduates — complaining that they’re unable to find a job in their chosen profession. To hear them tell it, there are too many nurses vying for too few jobs.

So, what’s going on? Is there a nursing shortage or is there really a nursing glut? The answer is yes and yes. Confused? Read on.

Failing Grade
According to the U.S. Nurse Workforce Report Card and Shortage Forecast, published in the American Journal of Medical Quality in 2012, over the next two decades, the demand for nurses will greatly outpace the supply.

Even states that currently have good nurse-patient ratios, like Massachusetts, are expected to slip to mediocre by 2030, so you can guess what that means for our fair state, which is already near the bottom of the heap.

California’s nurse-to-population ratio has ranked a dismal 48th in the nation for the past 10 years. In 2013, California had an estimated 657 RNs for every 100,000 population, well below the national average of 874 RNs per 100,000. The Nurse Workforce Report Card gave California’s RN supply a “D” grade and projects that by 2030, we will be more than 193,000 nurses short of our nursing needs. (So much for the wishful thinking 10 years ago that legally mandated nurse-patient ratios would somehow resolve our nursing shortage!)

By now, we’ve all heard the reasons for the predicted nursing shortage: an aging population that will need more care, more people having access to care due to the ACA and an aging workforce that’s not being replaced fast enough. It paints a worrisome picture.

Unprepared For Nursing School
Between 2001 and 2010, the number of people enrolling in nursing school here in California increased dramatically, leading to predictions that the state’s total nursing workforce would grow by about 60 percent between now and 2030. Currently, the reality looks much less rosy. According to a recent report prepared for the BRN by the Philip R. Lee Institute for Health Policy Studies and School of Nursing at UCSF, nursing school graduation rates for the past few years have been lower than expected and growth has been slow. Only 195 more nurses graduated in the 2012–2013 academic year than in 2011–2012, an increase of only 1.8 percent. The report predicts that graduations for the 2015–2016 school year will actually drop below the 2010–2011 level.

The number of licenses granted to foreign-educated and out-of-state nurses is also down. While fewer California RNs are leaving the state for greener pastures, fewer nurses are moving to California. As a result, the report forecasts that even in a best-case scenario, California’s RN supply will grow only about 10 percent by 2030 — not nearly enough.

The UCSF report recommends “growing our RN programs a bit more,” but that may be easier said than done. In California, many students are ill-prepared to enter a nursing program due to a lack of prerequisites like microbiology, statistics or psychology. Having to play catch-up will delay admission.

Students who do enter nursing programs may face a shortage of instructors. Quality nursing faculty is already in short supply and that shortfall is also getting worse.

New Grad “Catch-22”
If all that is true, why are so many newly minted RNs (both ADN-prepared and those with BSNs) having a hard time finding work? And why do many chief nursing officers in California believe there are more than enough RNs to meet current requirements?

First, keep in mind that the various estimates and projections of nursing shortages are for the state as a whole. California is a big state and even if you live in a county that’s been designated as a registered nurse shortage area (like Los Angeles County), that doesn’t mean you can just stroll over to your neighborhood hospital and get a job tomorrow.

Healthcare provider shortages are usually most severe in poor or rural areas where new grads may not think — or want — to look for jobs. Hospitals in more prosperous areas often have plenty of nurses and lots of applicants and can therefore be pickier about education and experience.

One of the most common demands is acute care experience, something in which far too many new grads are sorely lacking. Getting enough experience to satisfy a hospital recruiter may require some creative solutions on the part of new grads.

Back in the “good old days,” a new nurse could gather a plethora of real-world experience by working as a travel nurse, but today, most travel nurse services require at least two years of hospital experience prior to placement.

Adding to the frustration of the new grad looking for work is the fact that many current RNs are still putting off retirement. The UCSF report confirms that employment rates are higher among older RNs, many of whom continue to practice because they can’t afford to retire. That means new grads are competing for jobs with older nurses who have far more clinical experience.

The Spectrum of Staff Experience
While some parts of California do have a nursing glut right now, hospital nursing directors and chief nursing officers need to recognize that in many cases, the current honeymoon won’t last. Eventually, older nurses will leave the nursing workforce, either because the economy has improved enough to rebuild their retirement nest eggs or for health reasons.

The vacuum left by those departures will need to be filled — in all likelihood, by the same new grads being turned away now. Even without an overall RN shortage, such “backfilling” is critical to maintaining a healthy and vibrant nursing workforce.

During my tenure as a director of nursing, I worked hard to ensure that our hospital’s nursing team was as diverse as possible. A critical component of that diversity was having a wide spectrum of experience, from new nurses to seasoned veterans.

In that way, our experienced nurses could mentor the new grads, who would in turn bring a level of enthusiasm and cutting-edge knowledge that benefited their more experienced colleagues. It was a win-win situation.

What’s the outlook for new grads? There are nursing jobs to be had, but in the short term, finding one without acute care experience will continue to be a challenge. That leaves the new grad with a choice: If you don’t want to wait around for your more experienced colleagues to retire, you’ll need to either find ways to build your clinical experience or be willing to look for jobs in areas off the beaten path.

Few will deny that California’s nursing population needs to grow or that there are real obstacles to that growth that need to be addressed, such as the shortage of nursing faculty. However, it’s important to recognize that nursing shortages (or surpluses) are not cut and dried. The future of nursing in California is in our hands.

A Tale of Rabies

The only hope was a radical experimental protocol

By Genevieve M. Clavreul, RN, Ph.D.

We called him Peanut: a small, fragile boy who was admitted to our pediatric intensive care unit (PICU) at Columbus Medical Center in Columbus, Ga., in the late ‘70s with an infection we would later diagnosis as rabies.

Although rabies is no longer as common as it used to be in the U.S. — an aggressive public health campaign has reduced the number of confirmed cases from almost 6,000 a year in 1979 to fewer than three in 2010 — it is still a lethal disease that can test caregivers to their limits. When Peanut came to us three decades ago, it was an almost certain death sentence if not treated in time.

GRIM DIAGNOSIS
No one was ever quite sure how a little boy in one of Georgia’s larger cities had come to be bitten by a rabid animal. The most common carriers of rabies in western Georgia were raccoons, skunks, foxes and bats — not your typical urban fauna. Peanut’s parents had brought him to the emergency room with no idea of the nature of his illness and his symptoms had puzzled the ER physicians. When he was transferred to our PICU, the doctors were still unsure what was wrong.

Caring for Peanut presented some unique challenges. He was just a toddler and his age and condition limited his ability to communicate with the staff. We used a combination of sign language, pantomime and pictograms to quiz him on how he felt, where he had pain and so forth. His parents did their best to help, but they were as flummoxed by his condition as we were.

Rabies is a viral infection with three clinical stages. Peanut was admitted during the prodromal phase, which may include several days of flu-like symptoms. During the second stage, known as the excitation or “furious” phase, the patient may present with the symptoms commonly associated with rabies, such as dilated or rolling eyes, tachycardia, hyperventilation and hydrophobia. If the patient survives this phase, the disease moves into its third and final stage with the progressive onset of paralysis, stupor, coma and death.

Days passed as Peanut’s physician ordered test after test to whittle down the list of suspects. Then, Peanut presented with two of the unmistakable signs of rabies: a “locked jaw” and excessive salivating. The evening when I came on shift and saw the latter symptom made me and my team dread the impending diagnosis. Reviewing the likely outcomes left us on the brink of despair. Survival from rabies at that stage was so rare that it was not even included in the list of outcomes.

Our PICU team was by no means unaccustomed to death, but nothing in Peanut’s original symptoms had prepared us or his family for such a grim prognosis. How were we going to inform Peanut’s parents that their son’s most likely outcome was death?

THE EXPERIMENT
Later that day, our unit’s doctors and nurses held a meeting to discuss Peanut’s case. Since his condition was so advanced, neither rabies vaccine nor antiserum was an option. Instead, we decided to place him in an induced paralytic state, use supportive therapy to get him through the worst of the symptoms and hope for the best. (This was decades before the development of the Milwaukee protocol.)

After many telephone calls and much research on different paralytic drugs, our pediatric chief of staff settled on Pavulon, the brand name for Pancuronium bromide, a non-depolarizing curare-mimetic muscle relaxant. There was just one hurdle: Pavulon was not approved for pediatric patients and this off-label use required the approval of both the manufacturer and the FDA. Fortunately, after much finagling and promises to carefully document everything, our team got the necessary authorizations and set about developing a protocol for Peanut.

Since this was uncharted territory, we kept the protocol as simple as possible. We titrated the muscle relaxant until we discovered the minimum amount of Pavulon needed to paralyze Peanut. Doing so left him completely aware but unable to move, which was the only way to keep him from fighting the vent. (In those days, we had no inline suction and lacked the sophisticated equipment now available to anchor and stabilize an endotracheal tube.)

Our chief of staff then wrote a standing order to administer that same amount of Pavulon whenever Peanut exhibited any signs of movement. To help us monitor Peanut’s sedation level, we came up with an ingenious system of strings and mobiles that would move with his slightest motion. I can’t remember whose idea this was or where it originated, but it was wonderfully simple and very effective.

After many weeks, we were able to wean our patient off both the Pavulon and the vent. During this period, poor little Peanut could barely move his stiffened muscles, but every time he reached out for something or took a step, however stiffly or woodenly, we saw it as one more sign of a hard-won recovery from a devastating disease.

VITAL LESSONS
Peanut’s case was highly inspirational to those of us in the PICU, showing us that if we came together as a team, we could move mountains. He also taught me an important lesson: No matter what condition or state of mind patients may be in, they can still tell you a great deal about how the nurses interact with their patients.

As Peanut emerged from his induced paralysis, I noticed that there was one nurse on our team around whom he was visibly apprehensive. Later, when he was again able to move, he would run screaming from her into the arms of his parents or any other nurse who happened to be nearby.

At first, I couldn’t understand why Peanut would so be afraid of that particular nurse, who hadn’t subjected him to any procedure that hadn’t also been performed by every other nurse in our unit. It wasn’t until much later that I discovered Peanut had good reason to fear that nurse, who had a cruel streak that would eventually lead to her dismissal from our unit. She didn’t have the temperament for the PICU and Peanut was the first to catch on. I wish I had listened sooner.

HOPING FOR THE BEST
Eventually, Peanut was stable enough to be released and return home. I lost track of this spunky little patient as my life and career handed me other challenges. I’d like to think that he was one of the lucky few to survive his encounter with rabies, although the odds were against it.

As of 2008, there were only three known unvaccinated rabies survivors in the United States. Peanut might have been one of those three; I certainly hope so. I do know that I and the PICU staff at Columbus did everything in our power to make that outcome possible.

Split-Shift Floating – A quick-fix solution with serious consequences

As nurses, we’re familiar with eight-, 12- and even 24-hour shifts, but our profession has developed another unpleasant permutation that not all of us have yet encountered: split-shift floating.

Split-shift floating means that a nurse starts his or her shift in one unit and then at some point during the shift is moved to a different unit. Shift-splitting is most often done with registry or traveling nurses, although it occasionally happens to staff nurses as well.

Thankfully, shift-splitting is relatively rare, but it can be a sign that something is seriously wrong with the way a hospital manages its nursing staff.

Why It Happens
I know that a lot of readers have strong prejudices against registry nurses, but there’s no denying that they are a fact of life in many hospitals. In a perfect world, there would be no need for registry nurses, but in a perfect world, no staff nurse would ever call in sick, have to leave in mid-shift due to an emergency or quit at an inopportune time. Unfortunately, in the real world, those things happen all the time and when they do, many hospitals turn to registry nurses (also called travel nurses or just “travelers”) to pick up the slack, particularly in states like California that mandate minimum nurse/patient ratios

Registry nurses typically work through a staffing agency that contracts with the hospital to provide temporary nursing services. Because hospitals aren’t usually in a strong bargaining position in these negotiations, travel nurses are often hired on “pay or play” contracts, meaning the hospital is obliged to pay for a predetermined number of hours or shifts regardless of how many hours the traveler actually works.

That’s why when the patient census drops, staff nurses sometimes find themselves sent home while the registry nurse stays — the hospital is on the hook for the traveler’s time whether he or she is working or not! For the same reason, travelers may sometimes find themselves shifted from one unit to another during a single shift to make up nursing shortages in different areas of the hospital.

Where It Goes Wrong
Floating nurses from unit to unit on different shifts is not itself a bad thing and there are occasions where shift-splitting is unavoidable, albeit far from ideal. However, if they become commonplace,  “Houston, we have a problem.”

Splitting shifts can have very negative consequences for the hospital and patients as well as the nurses. Having to change units during a shift can lead to a whole assortment of errors ranging from incomplete charting to missed or late medication. Worse, if something does go wrong, other nurses may have to step in to fix it, taking time away from their other duties and potentially compounding the bigger problem.

Behind the Eight-Ball
To illustrate the disruptive nature of shift-splitting, here’s a recent night in the life of a travel nurse named Charlene, who has given me permission to share her story with you.

Charlene was scheduled to spend the first half of her eight-hour shift, from 19:00 to 23:00, in Unit A and the remainder of the shift in Unit B. Here’s a small sampling of her duties during her four hours in Unit A: One patient presented with glucose of over 400 with no order for a sliding scale, had a wound V.A.C. to address ulcers on one foot and needed a leg ulcer dressing change at hours of sleep.

Charlene managed to track down the physician and get an order to administer a stat dose of 15 units of NovoLog while caring for three other patients, one of whom presented with a persistent fever and prompted Charlene to seek a doctor’s order for straight catherization for urine culture and sensitivity.

Charlene managed to accomplish and document all these tasks and at 23:05 was ready to brief the nurse assigned to relieve her. Five minutes later, while giving that report, she got a call from the assistant nurse manager of Unit B demanding to know why she wasn’t there yet!

This is a common dilemma for nurses working a split shift: If they don’t take the time to make a full report to their relief, patients’ continuity of care is likely to suffer, but taking that time almost certainly means being late to the next unit and being chewed out by the manager there. Charlene aptly describes the whole situation as being “behind the eight-ball.”

Dirty Curtains
Obviously, this is not good or sound nursing practice. Unfortunately, nurses in that position don’t have much recourse. When Charlene spoke up, she was given a dressing down and warned, “When you’re in someone’s home, you don’t tell them that their curtains are dirty.” A travel nurse who complains too much about a hospital’s practices is likely to be rewarded with a “do not send” note in her agency file.

Staff nurses may not fare any better. How many of us have been (or seen colleagues) reprimanded or otherwise punished for pointing out an unsound or unsafe practice? Such punishments send a message to the rest of the team that they should keep their mouths shut or share a similar fate.

A Better Way
During my various tenures as a director of nursing, one of the first things I always tried to put in place was an in-house pool of floater nurses. This pool wasn’t simply plucked arbitrarily out of the nursing staff; it was a group of talented and adventurous nurses who had been carefully recruited and, most importantly, had volunteered for this unique and challenging assignment.

Building those pools took work (each nurse had to be a generalist with the right personality and the ability and desire to take on a diverse and ever-changing array of duties), but it allowed our leadership to respond to each unit’s day-to-day staffing needs with nurses who were up to the task — without needing to rely on travelers or shift-splitting.

The point is not that hospitals should  never float nurses between units or hire registry nurses, but it is vital that the nursing chain of command not allow short-term solutions to become routine practice. Responding to an occasional emergency is one thing, but regular shift-splitting or constantly relying on travelers rather than addressing ongoing staffing issues will just mean higher costs and more mistakes.

It’s also crucial for nurse managers to create a climate where the staff is not afraid to offer constructive criticism. At the same time, nurses must have the courage to speak up when they see an unsafe situation and not throw each other under the bus just to make it through the workday.

If more nurses made it clear that we as a profession won’t stand for unsafe nursing practices like shift-splitting (and won’t stand for colleagues being capriciously or unfairly punished for a valid complaint), it will make our hospitals safer, saner environments for nurses and patients alike.

 

~Geneviève M. Clavreul, RN, PhD

From The Floor

Working Nurse Magazine

Adventures in Patient Land

My latest column is out –

What Makes a Great Nurse?

There’s more to nursing than experience alone

By Genevieve M. Clavreul, RN, Ph.D.

In recent years, there’s been a lot of talk in the nursing world about education: advanced degrees, certifications and training in the latest technologies. However, this nurse has long believed that all the certifications and degrees in the world are no substitute for good basic nursing skills, including attention to detail, listening and, most important of all, a deep and abiding compassion for all the patients under your care.

I recently received a dramatic reminder of this point when my eldest daughter Patricia was unexpectedly hospitalized. Her experience left me simultaneously impressed and frightened about the state of nursing in the Golden State. (Before I begin this tale, I should note that Patricia has given her consent to my sharing her story with my readers, but I’ve redacted the names and certain details to protect the innocent — and the guilty.)

Unexpected Surgery

Patricia’s hospital “adventure” began with an emergency trip to her primary care physician. Patricia had seen the doctor earlier in the week about a persistent rash and swelling in her feet. Blood tests revealed that her hemoglobin count had dropped to 8.0; since 12.0 to 15.5 is considered the normal range for women, such low levels were serious enough to merit immediate hospitalization.

After Patricia was admitted, her hemoglobin count continued to fall even after she received several full pints of blood. A CAT scan eventually revealed a large abscess that had displaced her right kidney from its normal position to the front of her abdomen. As if this weren’t bad news enough, the scan showed that the kidney was basically a shriveled mass and no longer functioning.

To make a long and painful story short, Patricia underwent a six-hour surgery to remove the abscess and the nonfunctional kidney, after which she was intubated for several days. She also ended up in isolation after a nasal swab came back positive for MRSA. As of this writing, she’s still in the hospital, but her white blood cell count is back to normal, most of the tubes have been removed and she is once again allowed solid food. She’s looking forward to going home.

The whole spectrum

 

The quality of nursing care my daughter received throughout this ordeal ranged from superb to truly lousy. Here are just a few examples from both ends of the spectrum:

Good: One of the day nurses was consistently attentive and thoughtful, making a point of always speaking to Patricia each and every time he needed to perform any action that affected her, from taking her blood sugar (like me, Patricia is diabetic) to more invasive procedures like checking her two No. 19 BLAKE drains. It was a small gesture that made a big difference.

Extraordinary: When Patricia received her diagnosis and was told that her kidney needed to be removed, she was understandably overwhelmed and began to cry and fret. One of the nurses, aware of the situation, disappeared down the hallway for a moment and returned with a harpist who offered to play several songs for Patricia to help her relax.

Bad: After Patricia was moved from the ICU to a regular room, the nurse who received her made it clear that she considered Patricia a burden. When my daughter complained of feeling warm and flushed after starting a new, more powerful antibiotic, the nurse could barely find the time to answer a call light and refused to take my daughter’s temperature again until asked to do so by the charge nurse. Appallingly enough, the recalcitrant nurse was mentoring a student nurse at the time. So much for modeling good nursing practice!

Worse: Since Patricia has very fragile veins, her doctors decided she needed a peripherally inserted central catheter (PICC) line to continue her antibiotics. The nurse who was sent to insert the PICC line insisted that I leave the room during the procedure because she needed a sterile field, but seemed oblivious to the gnats flitting about her so-called “sterile field.”
To my dismay, she then proceeded to pick up items that had fallen on the floor and put them back on the top of her cart without cleaning them first. I finally ordered her out of the room and requested a different PICC nurse.

Some of the nurses were very nice, but seemed worryingly inept. For instance, when I asked one young nursing graduate what dosage of morphine she was about to give Patricia, the nurse had to leave the room and reread the order before she could answer — hardly a reassuring sign. So much for making sure you’re giving the patient the right meds!

Some of the nurses shaped up noticeably after they learned I was an RN myself and thus was keeping an extra-sharp eye on them. It was good to know they were paying attention, but it suggested that they had grown a little slack and lazy when they didn’t think they were being “graded.”

Even the best nurses on the hospital’s staff had their off moments. One RN, an excellent nurse by most standards, had the bad habit of picking up the trash can lid each time he disposed of something and then continuing with his patient care. This didn’t make him a bad nurse, but it was a bad habit that could have negative consequences for patients.

What really counts

It struck me during Patricia’s hospitalization that there wasn’t an obvious correlation between the nurses’ levels of experience and the quality of care they provided. There were seasoned nurses who acted like they were going through the motions and veterans who still behaved as if each patient was as unique and important as the first patients they cared for when they begun their careers 20 years ago. There were new nurses who seemed out of their depth, but some of the finest nurses we encountered had only been RNs for a few years.

There were also patient care assistants (PCA) who provided care as good as or better than the RNs they supported. One PCA was so attentive and conscientious that I was heartened to learn she had just received her RN license that night. It gave me hope for the future of nursing.

What made the difference was not so much each nurse’s experience or level of training, but his or her personal commitment to patients and determination to practice to the best of his or her ability. Simply put, some of the nurses cared for my daughter as if she were their own loved one and others did not. Speaking as both a nurse and as a worried mother, it wasn’t hard to tell the difference and it had a meaningful impact on my daughter’s experience.

upholding the principles

I know there’s no such thing as a perfect hospital and even the best healthcare professionals make mistakes or have bad days — we’re only human, after all. I also don’t wish to downplay the importance of education and the judgment that comes with experience. However, it’s important for us to remember that education and experience are not a panacea. Teachers and mentors can tell us over and over again about the importance of compassion and patient advocacy, but it’s up to us to uphold those principles at every stage of our careers.

We must never forget that we often see patients at their most vulnerable and those patients’ families and friends are counting on us to help restore their loved one to health. Our profession demands that we challenge ourselves to always provide the best care we can and not allow ourselves to compromise patient outcomes with bad habits or a poor attitude. When that happens, it tarnishes us all.