I just have to tell you this story. I swear it is true.

Last evening I was flying home from a Critical Care and Social Media conference in Sydney.

I had settled into my window seat and was flipping through the flight magazine. It was a smaller prop aircraft and everyone was pretty much seated, the last few stragglers flopping into their seats.
I love flying in these smaller planes as they cruise at a much lower altitude and you can enjoy the scenery passing by below. It was just on dusk so it promised to be a beautiful flight.

And then he boarded.
I heard him first. An apologising fluster of luggage and juggled stationary approaching from the rear.
I shall call him Mr Vicks for reasons that will soon be self evident.
Mr Vicks looked a bit like Jude Law, dressed in a light grey suit. I knew with certainty that he would be sitting next to me.

After a brief standing hello, Mr Vicks proceeded to unpack from the two black leather carry-on bags that he had placed in the isle.
Like a set of Russian Dolls, more bags were extracted and were placed on the seat beside me. Then some headphones. And after a considerable rummaging, an iPhone.

All but one of the smaller bags went up into the overhead luggage bin, followed by the larger bags. Headphones into suit jacket pocket. Jacket off, and hung over seat in front.

A cardboard folder that was struggling to contain a thick pile of what I would later peek to see were job applications spilled onto the seat. Mr Vicks leant over me to scoop them up.
Good grief.
The flight attendant moved in and assisted where possible with an icy smile.

Finally Mr Vicks settles into his seat. We taxi out onto the runway. And wait.

Mr Vicks then lifts the remaining leather bag onto his lap. It looks like a small black toiletries bag with a single zip across the top.
From inside he produces a bottle of decongestant nasal spray, clears his throat and squirts two loads into each nostril. After much wet sniffing and coughing he pulls some tissues from his kit and gives a loud extended bubbly blow.

Mr Vicks then holds his work out like an open book before him and inspects it intently. Very intently.

One Mississippi.
Two Mississippi.
Three Mississippi.
Four Mississippi.
Five Mississippi.
Six Mississippi.

He is way too close. And Six Mississippi’s is way too long to stare into your mozzarella laden hanky. I tried not to look.
But it was like….right…there.
Despite my greatest efforts not to, my eyeballs panned to the left. Screeching in their sockets like fingernails on a chalkboard.

Mr Vicks was tilting the wad gently from side to side. Perhaps trying to get the best effect from the overhead light.

Satisfied that all was as it should be, the tissues were stuffed into one of the aircraft sick bags. My eyes flicked forwards, you know, just to make sure I had my own sick bag.

Next. Out of the bag came a Vicks nasal inhaler.
Two big sniffs up each nostril, followed by some deep guttural hypopharyngeal sniffing.
Out with another tissue.
Aaaaand… blow.
Six Mississipi inspection.
Fingernails in my eye sockets.

Inhaler goes back into the bag.
Out comes another different spray. This time it was saline.
No doubt to soften up any last remaining tenacious tendrils of booger that may have resisted being expunged thus far.
Four sprays either side. Big wet inspiratory snort. Sounded like the last dregs of a chocolate milkshake being sucked up a straw.

Recovers the sick bag of tissues from between us and blows.

His pre-flight airway management complete,  Mr Vicks carefully packs away his kit bag and stows it down between his feet.

Turning to me for the first time as if he has just this moment sat down he beams, “Oh, how rude of me…..My Name is David. David Vicks”

And then Mr Vicks extends his hand to me… for a firm, moist,  six Mississippi shake.

Australian Emergency Departments all use the Australasian Triage Scale (ATS) to triage every patient presenting through its doors.
Triage can be defined as:

A process of assessment of a patient on arrival to the ED to determine the priority for medical care based on the clinical urgency of the patient’s presenting condition. Triage enables allocation of limited resources to obtain the maximum clinical utility for all patients presenting to the emergency department.’
The triage nurse applies an ATS category in response to the question: “This patient should wait for medical assessment and treatment no longer than….
Australasian College for Emergency Medicine. Policy Document: The Australasian Triage Scale

In Australia, the ATS is essentially a tool to sort patients according to clinical urgency, and studies have confirmed it to be reliable in doing so. At least for Category 1 and 2 presentations with some studies suggesting a bit of a drop in reliability for 3, 4 & 5¹.

Overall, our triage nurses do a pretty good job assigning an accurate score in an environment of high stress and workload. A study by Considine et al. found 61% of triage decisions were “expected triage” with 18% “over-triage” (that is, given a more urgent score) and 21% “under-triage decisions”²

To further improve triage quality and consistency, a national teaching resource has been developed known as the ETEK or Emergency Triage Education Kit. This kit is used in many emergency departments to train up new triage nurses as well as consolidating the knowledge and skills of existing ones.

It might be a good system but is it the RIGHT system?

So. We have a well crafted, effective and specialised tool at our disposal.
My question is this: is it the right tool to best manage the situation before us….right now?

Before you read any further, no, I don’t have an answer for this question. I certainly do not have any alternate solutions.
My thoughts on it all change when I listen to various expert peoples opinions. But after so many years of banging my head against the queue, I am both a little jaded and skeptical when it comes to the ATS.

I would love to hear your own views.

Our emergency departments have never been under greater stressors. Access block, overcrowding, pressure to meet National Emergency Access Targets, increasingly complex presentations from an ageing community.
Its bloody tough in here.

In 2009, the National Partnership Agreement on Hospital and Health Workforce Reform committed all the States and Territories in Australia to a performance benchmark that 80% of ED presentations will be seen within clinically recommended triage times.

A report card recently released by the Australian Medical Association has found that in 2011–12 only 66% of emergency department patients classified as urgent were seen within the recommenced 30 minutes.

Now this is for category 3 patients which is bad enough.
I believe the real canary in the coal mine would be seen if we had accurate and un-fudge-itated data on the national performance of our  category 2 patients during times of peak workloads.
These are time critical emergencies that should be seen within 10 minutes of presentation, some data that I have seen on these times (which to my knowledge is not in the public domain, & therefore I will not print here) is pretty grim.

And, again anecdotally, I have even heard of delays in category 1 (emergent) patients accessing definitive care, simply because there are no available beds to treat them in the unit.

The AMA report sumarised:

Health reform, as defined and constructed by governments, has failed to deliver direct improvements in the capacity of public hospitals to meet the clinical demands and performance targets placed on them.

(You can read the entire report as a pdf here: Public hospital report card 2013: an AMA analysis of Australia’s public hospital system).

When the triage system becomes a meaningless question.

Talking to my colleagues in my own and other hospitals, the feeling is that the waiting times in our emergency departments have now become so long that essentially the 5 tier ATS breaks down into a bit of a farce when the pressure is on.

The triage system in itself is still working fine. But within the context of its efficacy within our current environment of access block and overcrowding, it is simply does not achieve anything other than capturing data to be used later.

The essential question at the core of our triage system becomes meaningless: “This patient should wait for medical assessment and treatment no longer than….”
30 minutes?
Well no. How about 4 hours. Or 5. Or 7.

Basically there is little point sorting according to urgency if there is not an appropriate and timely response to that urgency.

Category 3 patients are waiting so long and build into such large group that they require sub-triaging within this category (we all do it no?). The waiting times may be so long that patients triage categories will change (sometimes several times) before they are seen.

Although officially locked into using the ATS, many emergency departments are now experimenting with other systems such as: ATS 1, 2 and then all other presentations seen in time of arrival³. Or systems based on complexity rather than urgency of the presenting complaint. Or some sort of mixed model.

There are plenty of other initiatives and workarounds that are being implemented at a local level to try to improve patient flow during peek workloads. Hey, way back in 2007 I even suggested my own tweak to the ATS to meet workload demand, a Dynamic Triage System.
Oh……I thought it was cool anyway.

Triage or Bricolage?

Today, triage nurses must triage to a queue, then care for it, and be accountable for it.

Bricolage is a term used to refer to the construction or creation of a work from a diverse range of things that happen to be available, or a work created by such a process.
The term is borrowed from the French word bricolage, from the verb bricoler, the core meaning in French being, “fiddle, tinker” and, by extension, “to make creative and resourceful use of whatever materials are at hand (regardless of their original purpose)”

Perhaps this is a better definition of what our triage nurses are doing.
What say you?

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Reference: http://www.acem.org.au/media/media_releases/2012_-ACEM_Triage_Literature_Review.pdf

1. Gerdtz MF, Collins M, Chu M, Grant A, Tchernomoroff R, Pollard C, Harris J, Wassertheil J: Optimizing triage consistency in Australian emergency departments: The Emergency Triage Education Kit. Emergency Medicine Australasia 2008, 20(3):250–259 [↩]
2. Considine J, LeVasseur SA, Villanueva E: The Australasian Triage Scale: Examining emergency department nurses’ performance using computer and paper scenarios. Annals of Emergency Medicine 2004, 44(5):516–523. [↩]
3. I would be interested in anyone’s thoughts on the medico-legal implications of this for the triage nurses when, for example they triage someone as a ATS 3 and then place them in the queue behind 7 other category 4’s and 5’s, (unless they are covered by local policy). [↩]

Night duty. Personally, I hate, hate, hate, hate it.
But I have the greatest respect for those nurses who either do a lot of it. Or chose to make it their life.

A study to be published in the Journal of Advanced Nursing looks at the experiences of nurses working the night shift at three regional hospitals in Australia.

Data was collected via questionnaires, interviews and diary entries over a six month period in 2010 and was augmented by a series of semi structured interviews.
Of the 14 study participants, 10 were on permanent night duty and all were female.

The results of the study found a very strong cohesive team amongst the night shift. But it also fond evidence of the night shift crew operating somewhat as a silo (or separated unit) from the rest of the shifts. And there were several themes around this:

Staff felt that they had to deal with a poorer working environment that their daytime colleagues, particularly around distribution of workload and staffing.
They also felt that they were required to work with much less resources and “sub-optimal” leader ship support from department managers.
They expressed feelings that the night shift nurses appeared to be considered of lesser value or ‘lower status’ than other shifts.

There was also a sense of disconnectedness from the organization that might stem from the organization not trying to involve night nurses in hospital activities and processes or from the night-shift nurses actively choosing not to become involved. The disinterest in governance issues could be ambivalence or direction of energies to departmental concerns.

Other concerns included access to professional development and educational opportunities.

With respect to the personal impact of working the night shift, participants felt that it had a major impact on their lives. Health, sleep and fatigue were a common theme along with expressions of feeling socially isolated.
Although some participants felt the choice to work night shift afforded them a unique opportunity to have a more flexible lifestyle.

The study also produced a set of recommendations to drive a positive change around the issues raised.

• Managers review current policy and develop new policy and practices as required.
• Managers consider how to build on the teamwork, co-operation, and collegiality practised by night staff.
• Managers consider strategies to improve communication and co-operation related to the night-shift role, responsibilities, and position
• Managers explore professional development needs of night nurses and develop strategies comparable to non-night-shift nursing staff to meet these needs
• Managers recognize that while night staff work with minimal supervision, they still need and desire leadership. Managers examine leadership options for night staff.
• Managers overtly recognize the contribution of night-shift nurses.
• Replication of this study in different geographical areas and facility settings.

The authors go on to conclude:

It is important that the key areas of interpersonal relationships, effective leadership, work environment, clinical competencies, and recognition of the critical role of night nurses be taken on board by managers to inform decisions that have an impact on night staff. This knowledge will assist ward staff, managers, and clinical educators to improve the work environment and potentially maintain a sustainable and effective workforce in regional hospitals. While management has a key role, non-night-shift co-workers must also rethink their approach towards their night-shift colleagues. Just as managers and non-night-shift nurses have a role in change, so do the night-shift nurses themselves, who must accept responsibility for implementing change through co-operation with management and peers.

Although this study had a relatively limited number of participants and was also limited to a small geographical area and particular type of rural healthcare setting, it provides some thought generating reading of any night shift worker.

If you are a regular night shift worker you might like to read the whole study and reflect on its relevance and similarity to your own experience.

Powell, Idona. “Can You See Me? Experiences of Nurses Working Night Shift in Australian Regional Hospitals: a Qualitative Case Study.” Journal of Advanced Nursing (2013).

There is an article published by Journal of Advanced Nursing, titled Mosaic of verbal abuse experienced by nurses in their everyday work that should be read by every nurse that has tolerated  demeaning or verbally abusive behaviour whilst on duty, and also by every member of the public who has had a nurse care for them.

This was an observational study conducted over 1150 hours at inpatient and emergency department wards in a large acute metropolitan teaching hospital on the outskirts of a major Australian city.

It found an everyday, sustained ‘mosaic’ of non-verbal threatening behaviours, verbal insults, threats and physical assaults.
This mosaic was classified into 3 categories:

• Verbal abuse that was largely sexual.
• Ridicule and unreasonable demands
• Hostility, threats and menacing language.

Verbal abuse:

Patients and less commonly their family and friends were observed to make sexualized insults, judgements, threats, or suggestions that targeted nurses through sexualized demeaning language. The sexualized taunts and insults conveyed stereotypical gendered assumptions about nursing and nurses. The sexualized and strongly pejorative language included descriptions of nurses as ‘c*nts’, ‘-’, ‘bitches’, ‘whores’, and ‘sluts’. The insults were made in public spaces in front of others. By labelling their femininity as deviant, these insults explicitly debased the character of a particular nurse by drawing attention to their supposed sexual worth. The following interaction was observed to occur in a busy waiting room; the outburst was triggered when a nurse did not bring ice quickly enough when requested.
Patients Friend (said about the nurses): ‘All these f*cking lazy c*nts, we pay taxes for this! She’s a f*cking whore’ (directed at the individual nurse).

Ridicule:

Demeaning insults included openly questioning whether ‘they (nurses) know how to do their jobs’ and debasing the character and competence of nurses was observed to occur through such accusations as: ‘You’re lying, you’re falsifying’, and ‘You are animals’, ‘You bastards… this is a joke’. Associated with these insults were attacks on services provided with remarks that they were ‘disgraceful’ and swearing and cursing that was directed at the actions of nurses through comments such as ‘bullshit’ and ‘for God’s sake get it right’. Patients and their visitors demanded nurses act more quickly, fetch the doctor ‘I need the bloody doctor’, or bring food when demanded ‘NOW’. Demands that followed gendered and sexualized attacks had an implied overtone of slovenliness: ‘Hurry up, there’s people waiting here, not only me, everybody else. F*cking hurry up’.

Hostility & threats:

By sustaining the hostile dynamic, these behaviours served to provide further opportunities for an escalation or continuation of the violence. Threats of complaint or legal action followed several incidents of verbal abuse and demand. In one incident, a family member complained: ‘Your hospital is going to be all over the media’ while she filmed staff on her camera phone. Threats of harm were observed to be directed occasionally at other treating staff (ambulance officer and doctor), but were most commonly aimed at nurses, either as a group or individually. The threats included several different types of violence: killing, shooting, blowing up, punching, and stabbing with a needle.

I have provided some short excerpts from this article but it is well worth trying to get hold of the entire study which is far more explicit.

It is interesting to note your own reactions when reading these accounts.
I cannot think of many other environments where this would be tolerated (could you imagine walking into a bank and telling the fucking bitch tellers to get your money out before you fucking job them? Yeah…good luck with that), yet often we consider the correct ‘professional’ response is to absorb or let the comments roll off our backs so we can get on with care delivery. Even when there are direct threats being made.

So. I would be interested in anyone who would like to recount their own experiences with verbal abuse whilst on duty.
What did you feel?
How did you respond?
What acute support were you given from your colleagues and from your hospital?

2013 is going to be a big year.

Over the last 12 months or so we have seen a huge growth in medical social media connectivity. The breadth and depth of high quality educational materials (or MEDucation as it is often now referred) available to us now for free is astounding.

And its not just education. Nurses are engaging with each other, sharing ideas and experiences, arguing and joking…and perhaps for the first time on the internet, we are seeing some first glimpses of something, I’m not really sure what to call it…. a deeper interpenetration between the separate worlds of nurses and doctors as we soak in each others experience… perhaps?

I have no doubt there are interesting times ahead.
The whole FOAM (Free Open Access Meducation) concept is growing from its recent nascence into a game changing movement. It is still wide-eyed and a little foal-wobbly right now but it is fast finding its legs. Make no mistake, it has gumption, and it has pedigree.

I think the following year will also see some interesting developments as the general public, patient advocates and regulatory bodies all become more aware of the much more overt nature of medical social media streams, and more astute at accessing (and interacting) with this body of information and conversations.

So what will 2013 mean for impactednurse.com?

Well, I am active on quite a lot of social media streams right now, but this site is my heart and hearth.
In 2013 I will really be working hard deliver lot more ‘stuff’ on this site.
As has always been the case, I have a few boundary issues here.
I struggle to define exactly what it is that impactednurse.com is trying be, and hold it up in comparison to some of the other most excellent websites out there, who seem to know exactly who they are.

But I, on the other hand, have always wobbled around all over the place.
On more than one occasion this site has been called quirky, which really used to make me bristle.
Quirky?….oh no, no, no, no , I put a lot of work into this place….its not quirky dammit!

But guess what. The Q word.

Clearly, when I try to be what I think I should be I just trip over myself.
Did you know that I often (very often) scrap posts because I imagine they are not what others may be interested in….or because I feel they do not meet the standards of other medical sites, or because I fear the judgment of those who I know and respect who might read my thoughts here?
Especially that last one. Yes boundary issues and self confidence issues.

Despite this I have always tried to capture a little of the art and soul of nursing on this site. As with all art (and most souls), the result can sometimes be confronting, other times (surprising even myself at what has just appeared on the page) deeply moving……and sometimes just plain bad. Way wrong bad.
I see this as my strength. Bad bits and all.

So for 2013 my resolution is to write down whatever splashes out as my heart, my head, and my spleen crazy-chase around this tank of skin.
Just write.
Just write.

My other project right now is Nurse+
I would really like this community to grow into a core of regular contributors and I will be working hard to nudge it along, and to convince nurses to regularly visit as a useful alternative to the (oftentimes) froth and bubble of Facebook.

So. 2013 will be a big year methinks, and I will try my damnedest to snag you along for the ride.