From Silence to Voice*

I am a member of the Institutional Review Board (IRB) at my university. IRBs, also known as independent ethics committees (IECs) or ethical review boards (ERBs) are committees that have been formally designated to approve, monitor, and review biomedical and behavioral research involving humans in order to protect the rights and welfare of the research subjects. While I sometimes gnash my teeth at the IRB when I'm working on my own research, I enjoy being a part of the board and interacting with my colleagues.

The reality is that there is not a lot of nursing presence on the university's IRB. It is mostly physicians, a few others who are involved with the research process, and the requisite community member. Over the two years that I have been on the board, I have contributed...adequately. I do my reviews, I occasionally ask questions or contribute my thoughts to the discussion. But at the last meeting I attended, I felt that I was present as the Voice of Nursing.

Usually, an IRB meeting has the same components -- reviewing and voting on the status of newly submitted studies, continuing reviews for on-going studies, and modification reviews for studies requesting changes. Occasionally, however we have to deal with Protocol Deviations. Protocol Deviations can range, but generally only those that cause harm or have the potential to cause harm are brought to the board. Last week's meeting included a review of a study with two major protocol deviations. The study is situated in the ICU, and utilizes very aggressive diuresising (i.e. giving medications--in this case IV furosemide--that causes one to eliminate fluid). One of the dangers with diuresis is that the process also causes a loss of potassium and can increase the blood sodium levels. Both of these processes are dangerous: potassium makes muscles contract, and either too much or too little can make muscles flaccid. Seeing how the heart is a muscle, this can be very problematic, and lead to icky things like heart arrhythmias. Sodium is involved in the transmission of electrical impulses, and since that's a very important part of brain function, this too can be very dangerous. Low sodium can cause delirium, high sodium, seizures.

This study had very strict protocols for stopping diuresis and beginning electrolyte and/or fluid replacement if the values go out of range. In this case, potassium got low, sodium high, the protocol was stopped....and then the furosemide was, for some inexplicable reason, restarted. By the time the situation was remedied, the subject's potassium was 1.8 (normal is 3.5-4.5) and sodium was 159 (normal is 135-145). When we questioned the study's principal investigator (PI), he said that a resident must have ordered the furosemide restarted, and while he did not speak with the resident, he and his team went back and worked with the ICU nurses, reeducating them regarding the protocol and electrolyte values.

Part of what I was trying to tease out was where was the root of the problem: was it a hospital systems/QA problem or was it an issue with the study? What I wound up addressing in the meeting was what is common knowledge/common practice for nurses.

First of all, electrolyte balance is nursing 101. Keeping track of critical labs like potassium and sodium is as natural to a nurse as breathing. I cannot imagine an ICU nurse not understanding what was going on, and responding accordingly.

But what really got to me, was the implication in the PI's comments that nurses blindly follow orders, whether they make sense or not. ICU nurses in particular work very collaboratively with providers, and are not known for shrinking away from making independent care decisions. Furthermore, any nurse worth her salt will not carry out provider orders that they feel are unsafe--a common response to a physician insisting on something a nurse feels is unsafe is for the nurse to say "fine, if you want them to have X, then you give it to them."

After the PI left, and the board was discussing the case, I felt it was important to raise these points. Not because they had direct bearing on the case in front of us, but because, as the lone nurse in the room, I felt it important that I remind those assembled of the scope of nursing practice, and of our skills and abilities. Even though it painted that specific nurse in a poor light, it felt more important to stand up for nursing as a profession, not as mindless "handmaidens to doctors." I'm not saying that that is how most providers perceive us, but as much as the public doesn't understand what we do, I sometimes get the sense that our colleagues and co-workers don't always get it either.

*Hat Tip to Bernice Buresh and Suzanne Gordon, authors of From Silence to Voice: What Nurses Know and Must Communicate to the Public

Credibility

Kim over at Emergiblog had a post recently discussing the relatively new phenomenon in nursing education of the "BS to PhD track." This course of study includes no masters, not even a courtesy masters: one goes straight from earning a BS in nursing to working on a PhD. Kim, a very popular blogger and long-time ED nurse who has gone back to school, took Diana J. Mason, PhD, RN, FAAN, the Editor-in Chief of the American Journal of Nursing to task for her position against this educational approach.

Interestingly, Dr. Mason replied in Kim's comments (I told you Kim was popular!) What she had to say ameliorated most of Kim's concerns, but it managed to make my blood boil.

Nursing is an odd profession/discipline in many ways. It developed from an apprenticeship model, not an academic model. Nursing education has evolved from hospital-based, physician-run programs that "grew their own" (and used the nursing students as menial laborers along the way), to being independent programs and schools within colleges and universities. Graduate programs are very new: the first masters in nursing wasn't available until 1956. The first doctoral level degrees specifically in nursing became available in, I believe, the 1970's.

From these two strands has developed a unique approach to graduate education. In most academic programs, individuals generally go directly from their undergraduate to their graduate education, often times straight through to their PhD. In nursing, the norm has been to get some kind of degree, whether it be diploma, AD, or BS, work for a number of years, then go back for a master's degree, and then, 10 or 20 years later, go back and get a PhD. Some of the accepted wisdom is that there is no way you can understand, never mind teach, nursing without a credible number of years "at the bedside."

Things started to shift in the past 10 years, with schools of nursing trying all kinds of new approaches, most notably "Direct Entry" for advanced clinical programs (aka Nurse Practitioner programs) for people who already had baccalaureate degrees and BS to PhD programs, moving individuals with a BS in Nursing directly into a PhD program.

There has been a great hue and cry against both these practices, because how can someone know anything about nursing, nursing practice, nursing culture, etc. without spending at least a decade doing it? And of course, by "doing it," the implication is that one is in a hospital and providing direct care, despite the fact that, according to the Bureau of Labor Statistics, only 59% of all nursing jobs are in the hospital (including managers, educators, and other non-bedside positions).

The bottom line for both Kim and Diana is that there is no way someone can graduate from a nursing undergraduate program, go directly for a PhD, and be either a competent instructor or a relevant researcher.

I beg to disagree. Furthermore, I'd say that there an awful lot of assertions being made based on assumptions without any empirical evidence.*

I am completing a BS to PhD program. Like a number of the BS to PhD students in my program, I come to nursing as an adult with a wealth of experience that can inform my practice. Just because I am learning a new skill set and knowledge base doesn't mean all my prior experience, education, and abilities are thrown out the window. There's a lot more to nursing than being able to place an IV or read and interpret a rhythm strip. There's interpersonal skills, time management skills, the ability to take in a great amount of information, sort, prioritize, act, respond...these skills are not the purview of nurses alone.

As to my lack of nursing experience, neither myself, nor any of my colleagues in my program have completed it without concurrently working as nurses, at least part-time. Frankly, I'm a little insulted by the implication that anyone smart enough to succeed in a PhD program wouldn't figure that they need to acquire clinical experience along the way. By the time I am finished with my PhD I will have been working as a nurse for 6 years.

As regarding clinically relevant research, I believe that the relevance of ones research is a lot more dependent on ones academic culture than one's work history. My program has always emphasized research which is clinically relevant in general and relevant to nursing in particular. I can't imagine being able to get funding, particularly in these tight money times, without meeting a need and filling a knowledge gap. Furthermore, I have already received feedback from professionals within the fields of end-of-life research, and nursing as well as patients and families that my research focus on family caregivers at end-of-life is filling a gap and a need. This feedback has included some very generous and prestigious funding

As for being a good educator, I am lucky that my program has excellent education offerings, developed under the leadership of highly respected experts on nursing education. I have already started to do some mentored teaching, and I've gotten good feedback from students and faculty about what I bring to teaching and the positive impact I have had in both the classroom and in curriculum development. I will go into my first faculty position a lot better prepared to develop curriculum and provide meaningful educational experiences than a lot of newly-minted PhDs with years of bedside experience. There is an expression "those who can't teach." The reality is that just because you are an expert in a field, doesn't mean you can teach the field's knowledge effectively.

I know I'm going to make a damn fine teacher and researcher. I know that my students will not be short changed by my not having worked a med-surg floor for 30 years. I know that the knowledge and understanding that I uncover in my research will be useful and relevant to practice, and will move the science forward.

*Some may say what follows is not empirical evidence but anecdotal. Well, as a constructivist, qualitative researcher, I would say it describes a particular reality from which guarded generalizations may be made.

How I Got Here

Over at Nursing Voices is a thread where people are describing things they like to do that other people find distasteful. I posted about enjoying providing postmortem care—removing all lines, washing the body, tiding the room…generally preparing the diseased to be seen by their family/loved ones.

There is a very specific reason I appreciate providing this particular service to patients and their families, and it ties very directly to why I became an RN.

I moved to my present location in 1995. Didn’t know anyone here but my cousin L, who I stayed with. Her partner J was involved with Our House, a place that was for people with “end-stage AIDS,” particularly those with no place to live or people to take care of them. People got to “end stage” pretty fast in those days: the first of the antiretrovirals, the protease inhibitors, were just starting to be used, the “cocktail” or more accurately Highly active antiretroviral therapy (HAART) was still at least a year off. The facility didn’t call itself a hospice because they didn’t want to deal with the Medicaid regulations, but in reality that was what it was. It was/is an amazing place – at that time the facility had 10 rooms and over 300 volunteers, nursing staff who worked for a lot less than they could make elsewhere, and the ability to get amazing donations (such as the custom made table for 20 that a local funiture maker made for them).

I moved not having a job lined up, just knowing I needed to get back to the west coast. I didn’t know anyone other than L & J, and decided to volunteer at Our House. Like most people who commit to a specific shift, I started out working in the kitchen. But shortly after I started to work, a new resident, S, came in who was deaf. I had been a sign language interpreter, and they asked me to spend time with S, and act as an informal interpreter when I was there (they hired working professionals for important things, but for the day-to-day communication, it was nice to have someone around who could facilitate communication). This got me out of the kitchen and a lot more involved with the residents, in particular S.

One of the philosophies of Our House was that no one should die alone. There was a list of volunteers who: 1) were willing to sit vigil; 2) wanted to be informed when someone was actively dying; 3) wanted to be informed when someone had died. I was on the list to sit with S when he became active. I stayed with him his last day and night. One of the odder things was that I sang to him – probably at least partly prompted by the fact that he would regularly talk about how when he died he would go to heaven and he would be able to walk again (he had progressive peripheral neuropathy/paresis) and he would be able to hear. I was with him when he died, helped to provide postmortem care, and was part of the procession to the van when the mortuary came to pick him up. As I continued to volunteer at Our House, I become a member of the “Personal Care Team,” basically someone who has CNA level training and could provide direct care to the residents. I continued to provide care, sit vigil, and provide what comfort and support as I could.

Fast forward to 1999. My father is diagnosed with acute myelogenous leukemia. He decides, despite the fact that he is 83 and has a very poor prognosis, to try an experimental chemotherapy. It does not go well, he is quickly hospitalized, becomes delirious, and begins to decline. No one thinks he is going to live very long. I am now managing a CAM clinic and can only go down to see him on weekends. When I am there, I stay in the hospital with him at night. Six weeks after diagnosis, he dies—his symptoms (especially pain) not well controlled, and having received what I see as indifferent care. I am there when he passes. I put on the call light, the nurse comes in, I tell her I think he has died. She checks a pulse and then disappears. Never says a word to me. A while later a doctor comes by and pronounces his death. Again, never says more than ten words to me. I call my mom and sibs to let them know what has happened. I try to get the nurse to take out the lines before my family shows up, and all she does is disconnect the IV. I bully her into giving me some washcloths and a clean gown so that I can make him as presentable as possible before the others arrive.

I am also furious. From my experiences at Our House, I know what a good death looks like. (The Institute of Medicine describes a good death as one “free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families' wishes; and reasonably consistent with clinical, cultural, and ethical standards”), and I know my father didn’t have one. It takes me another two years, but I finally realize that what I want to do is be a nurse, and work with those at end of life: do what I can to help as many people as possible have as good a death as possible.

One final note to this story. When I was finishing up my nursing undergraduate work, my final rotation was in the ICU. One of the patients came in with a subarachnoid bleed. After a while, when it was clear that he would not regain consciousness, the decision was made to withdraw life support. I helped with the process and the titration of pain medication to make sure that he was comfortable, and after he passed I asked his nurse (not my preceptor) if I could help with the postmortem care. It felt like I was somehow paying forward for the treatment my father had received.

Are You a Nurse?

Back in December, my mother was having knee replacement surgery. Six months prior she had had her other knee replaced, and there had been complications: delirium, probably from dangerously low sodium. Her surgeon was going to discharge her despite the obvious mentation changes and had to be practically bullied into running blood tests to check her electrolytes.

So after the second knee surgery, when the hospitalist (with residents in tow) came to check on her, I started to advocate strongly for what I felt was a necessary level of care. About five sentences in, he turns to me and says "are you a nurse?" At first I felt a little defensive (I was afraid he was perceiving me as a meddling relative), however when I said "yes," his response was to say "OK, then I'll explain things in more technical terms, and you can explain to your mother."

Last night, a family member called in asking about their relative. I didn't know the patient very well, they had been admitted while I was off, but I was looking through the notes trying to garner more information, and as we were talking the caller started to ask more technical questions, as well as explain things about the patient that was not clear (or downright wrong) in the chart. Almost unbidden from my mouth came the words "are you a nurse?"

Pause.

"Well yeah."

"OK, then I'll go into detail about what this report states."

Nothing like having the shoe on the other foot to gain better understanding of how we humans behave.